On occasion I am asked, “What sets orthopedic massage apart from other massage therapy techniques?”
Anyone who knows me knows my standard response: “Orthopedic massage is not a technique!” I usually add that there are several styles of orthopedic massage in the profession now that differ substantially in content, focus, methods and required skills.
However, most orthopedic massage training providers at their core have a focus on musculoskeletal pain and injury treatment, with differing gradations of what is taught regarding assessment and treatment. Most providers integrate techniques from across the field to maximize treatment diversity and options.
How assessment is integrated and the expected level of skill and knowledge required for the therapists, however, runs the gamut from only a little to a lot.
I have found clinical reasoning to be the one of the most challenging concepts for practitioners—and yet, it is critical for addressing pain and injury conditions. It is assessment that grounds clinical reasoning in advanced massage therapy. In this article, I want to explore why clinical reasoning skills are so necessary and provide an example of how they are best used by the therapist.
The Value of Clinical Reasoning
Massage practitioners have clients with a wide array of challenging musculoskeletal pain conditions. There are two key components to skillful pain and injury treatment: assessment and treatment. In the context of musculoskeletal pain or injuries, assessment skills include gathering key information from the client as well as the more detailed physical examination, generally referred to as orthopedic assessment.
While there are some general guidelines about specific conditions that a practitioner should be familiar with, the experienced practitioner knows that each presentation is unique. Thus, knowing the why, when, how and what of their client’s condition is paramount to launching a successful treatment protocol. Assessment explores these questions.
Why did the injury or pain complaint occur? When (age of injury; acute or chronic; repetitive or singular)? How (biomechanical forces involved)? What (tissues involved, physiological nature of tissues, injured how)? To answer these questions, assessment is the primary approach.
Similarly, an understanding of when, why, what and how to apply therapeutic treatments is crucial in orthopedic massage.
For example, when (treatment timing—now, wait, not at all); why (specific treatment goals regarding primary tissues or systems involved); what (which tissues); how (what methods fit the goals). Determining appropriate treatment choice is the essence of clinical reasoning.
In sum, recipes that suggest you do X treatment techniques for Y condition only get you so far and may impair your success. Clients are individuals, and there are numerous reasons why a standard treatment could be appropriate for one person and not appropriate for another. We rely on clinical reasoning to help make the determination if a particular treatment strategy is appropriate.
So, how does one figure all this out? That is the essence of integrating assessment and clinical reasoning for complex decision making. Savvy use of assessment helps you gather the key collection of puzzle pieces, the clinical signs and symptoms. Clinical reasoning is the cognitive tool to put the puzzle together. Those skilled in assessment and clinical reasoning advocate that any treatment strategy is highly limited and much less effective without good assessment and clinical reasoning to direct the treatment.
An Effective Treatment Plan
In massage therapy, clinical reasoning is basically putting together clinically relevant knowledge to make an informed decision or analysis. It is much more than an accumulation of facts. The skilled practitioner is able to apply concepts from such various subject areas as pathology, biomechanics, physiology and anatomy to each unique client presentation. Then the practitioner can reason through an appropriate assessment and construct a therapeutically effective treatment plan.
A key characteristic of good clinical reasoning is effective application of deductive reasoning. Deductive reasoning is what occurs with an “if, then…” statement. For example, if this client reports sharp shooting pain in the upper extremity along with paresthesia on the ulnar aspect of the hand, then there is a good chance the pain complaint is originating from some neural pathology in either the neck or upper extremity. This deductive analysis helps us determine if massage is appropriate and if so, how we should apply it.
Clinical reasoning in the assessment process is particularly well-illustrated by what occurs during our basic physical examination methods.
Let’s suppose a client presents with a shoulder compliant that resulted from a recent forward fall on an outstretched arm to brace the fall. The client reports deep, aching shoulder pain that was not reproduced with palpation of superficial tissues around the shoulder. After taking the initial history and performing some basic palpatory examinations, various active, passive and resisted movements are used to assess symptoms.
The internal shoulder pain is reproduced with active and passive flexion but not during resisted flexion. The pain was also reproduced, but not as strongly, with active and passive abduction. No other resisted actions reproduced the pain.
At this point, we have a series of puzzle pieces of information accumulated from our physical examination methods. This is the point where many practitioners get stuck. They have learned how to perform these range of motion evaluations, but not how to interpret the findings. This interpretation is clinical reasoning in action.
The first thing that becomes apparent is that this client had pain with both active and passive movement. If the same pain is present with active movement and passive movement, this usually points to a non-muscle structure as the cause of pain because the muscle would be engaged during the active movement but not during the passive movement.
This pattern is further confirmed because there was no pain during the resisted movement, which exclusively focuses on the muscle-tendon unit. This same pattern was evident in both shoulder flexion and abduction, although somewhat less in abduction. Based on this information, there is a strong likelihood that a non-contractile tissue such as bursa, ligament, nerve, cartilage or joint capsule is the likely source of this problem.
So, how would you narrow that down further? We have some more puzzle pieces of information that can be put together and add to our reasoning process.
There was no pain reproduced with palpation of superficial tissues around the shoulder. Most shoulder bursae that are aggravated with various motions are relatively close to the surface and pain can usually be reproduced by palpating these tissues. That would indicate that pain in the bursa is not as likely.
The pain was reported after a fall on an outstretched arm. Biomechanical analysis of the fall position is crucial here to determine various forces that were transmitted through the upper extremity to the shoulder region. If the individual fell forward on the outstretched arm, it would have thrust the humeral head in a posterior direction in the glenoid fossa. This mechanical force would stress several non-contractile tissues in the shoulder region.
However, this motion would not be as likely to damage nerve structures in the shoulder or upper extremity. In addition, the client did not report any neurological sensations extending down the upper extremity, which would be common with a nerve injury. Therefore, it would appear less likely that neural structures are at fault.
Putting these pieces of the puzzle together, we can now narrow our attention to a number of deep joint structures such as the glenoid labrum, joint capsule, or supporting ligamentous structures of the shoulder. We may not be able to determine with absolute certainty which of these tissues is primarily at fault, but this process of analysis and reasoning has greatly helped us identify the most likely culprit(s) in this pain complaint. We now have a solid rationale to direct our treatment or for referring this client.
Patterns of Information
Accurate evaluations rely on the right amount of information. If the practitioner only gathers a small amount of information in the assessment, it will be difficult to make an accurate clinical determination about what is wrong, whether or not massage would be appropriate, and what treatments best fit the situation.
However, a practitioner may not understand how much they don’t know in their assessment and evaluation process. If they go forward with treatment or referral recommendations, they can make mistakes. That’s not to say that mistakes are not made even with superb evaluations, but that a lack of knowledge complicates things.
Researchers have looked into what separates experts from novices in health care professions. A key factor is that experts develop certain shortcuts by recognizing patterns of information that novices might miss.
Solid clinical reasoning does rely on a strong background of foundational knowledge. But it is not the accumulation of a large pool of facts that made this clinical evaluation effective. Essentially, it was the process of using cues, pertinent information and the analysis of common patterns that narrowed down the primary problem.
Integrating Clinical Reasoning
One of the biggest challenges clinicians face is how to learn clinical reasoning. You can easily find workshops or training programs on specific techniques, but not on courses focused on clinical reasoning. That is mainly because clinical reasoning is a process that evolves out of accumulating knowledge and experience in a variety of different disciplines.
Good training in clinical reasoning puts more attention on teaching the practitioner how to think and generally comes in programs that are fully comprehensive and use methods that allow the student to learn through cognitive application.
In the massage profession, it is common for practitioners to simply not know what they are missing in terms of their own skills and thinking. This lack of knowledge can result in both assessment and clinical reasoning skills not being incorporated into sessions. In pain and injury treatment, this can be a sad error for the client. Once a practitioner discovers the value of this aspect of treatment, then skill development can begin.
Integrating sound assessment and clinical reasoning processes requires going through the same three general steps of learning any new skill: realize what you are missing (assessment skills, clinical reasoning); acquire the new skills and practice; and become adept and proficient.
Practice with the skills allows us to recognize symptom patterns and know what they mean and what they indicate. Proficiency allows us to get nimble, quick and efficient.
We don’t need recipes. We know how the tissues function and what symptom patterns and pain responses mean, so we can make our own decisions on what treatments would be most physiologically appropriate. In the end, the practitioner excels in their ability to help their clients, and clients get superior treatment.
About the Author
Whitney Lowe, LMT, directs the Academy of Clinical Massage, and is the author of Orthopedic Assessment in Massage Therapy and Orthopedic Massage: Theory and Technique. He teaches continuing education in advanced clinical massage through the academy, and offers an online training program in orthopedic massage.
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