The Crucial Importance of Learning Assessment

In this issue we are taking a fresh look at what assessment actually is and how best to learn this often underappreciated element of advanced massage treatment. I’ve written a good bit on this topic over the years because it is so important. Unfortunately, to some it is intimidating, and thus avoided or excluded in practice. Yet, assessment doesn’t have to be discounted or intimidating like this. In fact, for the most part one rarely needs to get into complex assessment strategies with a client.

Learning just the basics of orthopedic assessment will nearly guarantee better results and more satisfied and happier clients. Sounds like a sales pitch. It’s not. Good assessment drives your treatment decisions and when your treatment protocols are specific and targeted to the client’s issue, superior results follow. And I am not referring to the most complicated assessment process. Sometimes it’s a simple range-of-motion test done at the right time, with a few select questions that helps resolve a client’s problem most effectively.

The term ‘assessment’ used in our profession involves many methods such as asking questions, palpation, postural analysis, specific evaluation techniques, and special orthopedic tests. Orthopedic assessment originally developed within the medical branch of orthopedics. Many of these same strategies are directly applicable to our work.

The basic components of assessment are history, observation, palpation, range-of-motion and muscle-resistance techniques, and finally, special orthopedic tests. The most important thing to understand about assessment is that it is a process, not one technique. By definition, it is a systematic process of gathering information. This is what distinguishes assessment from diagnosis, which is more advanced testing and evaluation that concludes with a specifically named condition.

Initial assessment steps will help you figure out first if the condition is even something in your scope of practice and second, if massage is the best treatment solution. If not on either, referral is warranted. The basics – history, observation, and palpation – give you a roadmap for choosing which physical examination methods will elicit the most information. Clearly, no client will have the patience for or enjoy the practitioner simply running through an A to Z list of tests with them. We determine which tests are appropriate with information gained from the early steps in the process.

The most pertinent information from the physical examination comes from recognizing patterns and interpreting responses from range-of-motion and manual resistance tests. For example, if a client has pain with active shoulder abduction but not passive shoulder abduction, what does that mean? The interpretation of the results is what makes these assessment strategies such an advantage in the clinic, but often a challenge. The complexity of this clinical reasoning is the primary reason assessment is not taught in real depth in most entry-level training.

The range-of-motion and resistance testing procedures are easy to learn and you’ll be amazed at your increased treatment success as you develop skill with accurately interpreting the results. Once you get good at this, you will impress your clients far more than if you did the ‘so and so’ test (without really having a good context for WHY you were doing it).

Accurate analysis of these tests makes it obvious to your clients that you understand their anatomy, biomechanics, and how the body functions when injured. The reason being that these tests are not a simple ‘true/false’ about a condition (as special tests are). These tests give you important information to direct your treatments. Range-of-motion and manual resistance tests require that you be able to interpret the results – you figure out what they mean based on your knowledge of anatomy, biomechanics, and soft-tissue function/dysfunction. These are impressive skills and using them effectively will improve your treatment success and wow your clients in the process.

Some practitioners skip basic range-of-motion assessments in favor of slick sounding ‘special’ tests, which evaluate for a specific condition. An example would be the common Phalen’s test used to identity median nerve entrapment in the wrist. Most orthopedic assessment texts are filled with dozens, if not hundreds, of these special tests. It can seem overwhelming to learn and rote-memorize all these tests.

A simple special test sounds logical. Why not just jump to a test that will confirm what I already suspect is going on for the client? It doesn’t work like that. Jumping to special tests is jumping to conclusions, rather than gathering information. Sure, they will tell you something, but they often do not provide the level and detail of information you can elicit from doing range-of-motion and muscle-resistance testing thoroughly and accurately first. In addition, without having first performed some of the range-of-motion tests you may interpret the special tests inaccurately.

I am not dissing special tests, they have their roles. However, they come with limitations. The first is sensitivity, which means how accurate the test is at picking up everyone who has a specific condition. If the test is not very sensitive it may not give accurate information about a condition’s presence when the client has it. The second important factor is specificity, which refers to how accurate the test is at ruling out people that don’t have a specific condition. A test might be great at producing positive results indicating when a condition is present, but if it also gives positive results when the client doesn’t have the condition, it is of much less benefit.

I have been promoting the importance of comprehensive assessment for 30 years. Accurate and efficient clinical reasoning with these tests takes you to the primary tissues involved and helps illustrate the likely nature of the injury. It is through orthopedic assessment that we gain a better understanding of the physiological, biomechanical and psychosocial factors that may be playing a role in a client’s complaint. Accurate, informed understanding of your client’s problem, the tissues involved, the nature of the condition, and other critical factors is what leads to successful treatment.

One of the biggest challenges with teaching assessment is that it is not a discrete skill set, but rather a complex process of clinical reasoning. This element is hard to teach in the classroom, and it is very difficult to teach in the typical 2-day weekend CE workshop. This challenge is what drove me to look for more effective ways to teach these essential skills to massage therapists. Interestingly, I found the online format solved this problem better than any other strategy.

After decades of research and experimentation I have found the most effective methods for learning assessment involve repeatedly being challenged with decision making activities. It is also crucial to apply the learning from those clinical decisions. With online learning we can make the learning more personalized for each practitioner’s unique background. Online presentation also provides the opportunity for a wider group of students to have these learning opportunities as the course is not limited to one geographic location.

With over 68 million office visits to massage therapists each year to address musculoskeletal disorders, we owe it to our clients to put forth significant effort to develop a good understanding of their current condition so we can make the most responsible decisions about treatment or referral. Massage therapy has tremendous potential to fill this critical gap of musculoskeletal care in the healthcare system. However, as responsible health care providers we really must know what we are doing. Learning and practicing effective client assessment is a critical step in this process.