clinical assessment

Question 1

soap

Answer 1

 SUBJECTIVE
What guests say about their condition
Their perception of the condition since the last treatment

 OBJECTIVE
Obvious differences you notice before, during and after the massage

 ACTIONS AND ANALYSIS
Which techniques or modalities were used
Which areas were the focus of treatment
Results of the current massage session
Prioritized functional limitations
Long and short term goals

 PLAN
Plan for future massage treatments
Techniques to use or avoid, duration and frequency of future sessions
Self-care recommendations
Any specific products needed
Bath Salts, Thera-bands, Wobbleboards etc.
Referrals to other health care practitioners

Question 2

DAR

Answer 2

 DATA
Combined Subjective and Objective information
Observation, Palpation, Movement Assessments

	More condensed and brief then SOAP charting

 ACTION

	Similar to SOAP charting except more condensed and shorter

 RESULT
What is the final outcome of the treatment session
Plan for future sessions
Similar to “PLAN” in SOAP charting but more condensed

Question 3

pain tension cycle

Answer 3

 What happens with stress?
 Stress is the physical reaction you have to a stressor.
• A stressor is anything that you perceive or feel causes stress.
 Stressors may be from our environment – eg. Conditions on the worksite, loud noises, demanding schedules etc.
 They may be from our own bodies – eg. Physical illness
 They may be from our own perceptions of things – eg. Being stressed.
 Some responses can add to the stress and become stressors –eg. Alcohol consumed/drugs to relieve stress

Question 4

 Intake Form

Answer 4

 A form that documents the guests contact information, health history, or informed consent for care

Question 5

 Confidentiality

Answer 5

 Information that is to be kept private unless the guest expressly permits you to share it

Question 6

massage treatment record

Answer 6

 The document containing your subjective and objective regarding the guest’s condition as well as the results of the treatment session and plans for future sessions

Question 7

ADL activity of daily living

Answer 7

 Normal activities performed during an average day

Question 8

functional limitation

Answer 8

 A normal ADL that is limited by muscular or connective tissue conditions

Question 9

treatment goal

Answer 9

 A specific goal that is determined after therapeutic massage treatment to clarify progress toward restoring functional limitations

Question 10

case history question 1-4

Answer 10

 1) Lifestyle Questions
(age, gender, activity level, occupation, fitness, etc)

 2) Pain/Complaint Based Questions
(intensity, duration, pathway, makes it better/worse, any other pain I should know about?, etc.)

 3) Affected Activities of Daily Living (ADL’s) Questions
(e.g. what can’t you do that you could do before? How are you compensating for this loss/pain/other? Etc)

 4) Other
(medications, stress levels, other medical issues I should know about?, support system at home, etc)

Question 11

orthopedic format of assessment

Answer 11

HOPMNRS
History
Observation
Palpation
Movement
Neurological
Referred/Radiating Pain
Special Tests

Question 12

reflective listening

Answer 12

A method with which you reiterate the guest’s words to convey your comprehension or to clarify a misunderstanding

Question 13

rapport

Answer 13

A mutual trust in a relationship

Question 14

treatment goal

Answer 14

A specific goal that is determined after therapeutic massage treatment to clarify progress toward restoring functional limitations

Question 15

THE 4 QUADRANTS ARE:

Answer 15

Lifestyle Questions
(age, gender, activity level, occupation, fitness, etc)
2) Complaint/Pain Based Questions
(intensity, duration, pathway, makes it better/worse, any other pain I should know about?, etc.)
3) Affected Activities of Daily Living (ADL’s) Questions
(e.g. what can’t you do that you could do before? How are you compensating for this loss/pain/other? Etc)
4) Other
(medications, stress levels, other medical issues I should know about?, support system at home, etc

Question 16

PAIN COMPLAINT QUESTIONS

Answer 16

Has this happened in the past?
Determine ‘when’ did the complaint started – referred to as the ‘onset’ of the problem?
Was trauma involved, or it just started, or is it due to degeneration of the joints, age related or previous injury
Do you take any medications?
Any family with similar complaints?
Have you seen a physician for this concern, or any other practitioner?
What was the results of the visit
How has this condition affected their ADL
Was there any specific ‘mechanism of injury’ - describe it
Is there any pain involved

Question 17

locate the side of pain with FIDDO

Answer 17

Frequency
Intensity
Description
Duration
Onset

Question 18

pain related questions

Answer 18

AREA where does it bother you
NATURE describe what it feels like
BEHAVIOUR does it come and go come at night or morning certain movements hurt more?
DURATION is it constant or do you only feel it when you’re sitting or walking
FREQUENCY every hour? 20 minutes day?

Question 19

pain pressure scale

Answer 19

Used for Quantifying Pain
Excellent Resource for monitoring progress
Pressure Scale used for Manual Skills Purposes

Question 20

pain based questions

Answer 20

Any activity makes in worse? Activity that makes it better? Loss of ROM?

Any other symptoms such as numbness and tingling

Is it getting worse or better with time?

Are you using any pain medications?

On a pain scale from 1-10 – 10 is the worse pain ever experienced - where on that scale is the current pain?

Question 21

an RMT’s goal is to get to

Answer 21

100% pain free functional movement or as close to it

Question 22

affected activities of daily living questions

Answer 22

Function: Basic Personal ADL’s
(e.g. what can’t you do that you could do before? How are you compensating for this loss/pain/other? Etc)
What Daily Actions have been affected by this condition?
Bed Activities – moving in bed, managing pillows/blankets, reaching for objects (water/night lights), sitting up
Hygiene Activities - Brushing Hair/Teeth, Bathing and Showering, Washing, Toileting, Shaving, Putting On Makeup

Question 23

cont

Answer 23

Eating Activities – using utensils, cutting meat(or tofu), managing a glass and cup
Dressing Activities – putting on clothes, tying laces, putting on socks and shoes, fastening a bra, putting a shirt over head.
Transfer Activities – Bed to chair, sit to stand, getting into car, getting on bus
Walking Activities – Level and uneven surfaces, curbs and stairs, opening doors, walking and carrying items, distance and velocity, assistive devices, gait deviations

Question 24

short term goals

Answer 24

1-2 weeks

each stg should support ltg

Question 25

long term goals

Answer 25

Set up for guests to achieve within 1 to 2 months and are based upon their primary areas of concern.

This time frame varies with functional stress, chronic conditions that require time to heal, and a client’s desire to return to the most functional state of health over time

Question 26

consent to assess/treatment

Answer 26

Often called “consent to treat” or “informed consent”

Means that the guest understands and agrees to what the therapist is suggesting

Required by law

Enables guest to make an informed decision

Question 27

consent to assess/treat cont

Answer 27

Then after the therapist completes their Assessment a treatment plan is offered to their guest

A verbal treatment plan is simply an outline of what the therapist proposes to do in the treatment session.

“Today we are going to do some extra focus on your sore shoulder, while also giving you a full body massage, I will also be spending some extra time on your scalp as you had mentioned how much you like scalp massage, do this sound like a great plan to you?”

Question 28

ask what they are they for

Answer 28

even if they’re there for an injury if they just want to relax then give them that

Question 29

postural assessment

Answer 29

looking at bones with xray vision

Question 30

what the bones tell us is what is happening with the

Answer 30

muscles

Question 31

watching people shows you their habits

Answer 31

which gives you clues to their postural

Question 32

lack of self care is a sign

Answer 32

of depression

low self esteem etc…

Question 33

if someone has been drinking

Answer 33

pain sensation has dropped

contraindicated

Question 34

observation

Answer 34

These are the visual clues the therapists looks for in order to gain objective information about the guest’s condition

The observation gives both subjective and objective information about the guest

In addition to the visual aspects of observation other aspect includes careful listening techniques, and smell
(i.e. alcoholic breath)

Question 35

observation cont.

Answer 35

During an observation of the body the therapist is looking for signs that are related to, or may contribute to the guest’s complaint/s.
One important aspect of observation is a general soft eye ‘postural scan’ observation. Refer to the Postural Scan Observation chart.

Question 36

soft eye

Answer 36

general appearance look passed someone behind them skin and fascia how are they breathing clothes falling etc

Question 37

hard eye

Answer 37

look at the bones rotation levels etc specific

Question 38

communication and consent

Answer 38

How you ask your guest’s permission to perform a PA is almost as important as the test itself. Remember – no surprises
Choose your words wisely.
Ask them to dress down to their shorts and sports bra rather than “undress”
Always ask if they’ve understood why it is important.
Do you have any questions?
May I proceed? (ask for consent

Question 39

do i have your consent to proceed?

Answer 39

say i going to assess and view your posture

give me an idea of your chief complaint

Question 40

start from feet up with assessment

Answer 40

it’s where your anchored to the ground