An image of a hand holding a pen and writing a report is used to illustrate the concept of writing a massage therapy case report.

Have you had a significant clinical experience with a client? Writing and publishing your findings as a case report helps others expand their understanding of massage and improve practice. Here, we will explore how to write a case report.

The Massage Therapy Foundation defines a case report as a “description of a client seen in clinical practice which is written in a scientific manner.” Published case reports are most helpful when the case features a unique or unusual presentation, a rare diagnosis or an unexpected outcome. A case that challenges conventional theories or provides additional insights into the impact of massage for a particular condition is ideal.

Case reports have a structured format to ensure they are clear, concise and appropriately inform the reader. The scientific format consists of an abstract, introduction, methods (a description of the case and the massage techniques used), results and discussion.

Although case reports are written in the same manner as research reports, they are not research. Research studies test a hypothesis and systematically examine the relationship between topics of interest. A case report simply describes a therapist’s experiences of the treatment process for a single client. Its purpose is to inform an audience about an important issue and document the approach the therapist used to investigate that issue.

To write a case report, one must identify a suitable case. The client’s privacy must be protected and their medical information be accurate and complete. Once consent is obtained, the therapist should gather all relevant information, including the client’s history, medical findings and treatment, and conduct a literature review.

A literature review involves collecting and organizing all relevant published information about the case from peer-reviewed journals. (Notable databases are the National Library of Medicine’s PubMed and the International Journal of Therapeutic Massage & Bodywork.) It is important to research the relevant literature thoroughly to provide context for the case.

The Introduction

The introduction provides a brief background of the case and its relevance. A synthesis of the literature should be presented in the introduction to build the rationale for the case. There should be enough background information on the condition being studied for a reader to understand the topic.

A well-written case introduction is presented in a succinct and coherent manner, weaving in evidence to present the case for publication. Findings of previously published studies must be presented to help explain why the current case is of scientific interest. This is the literature review and it should be exhaustive, relating to the topic of interest. Extraneous information should be excluded.

If existing treatment-related research is limited, related articles (possibly some in other fields) can be used to support clinical decision-making and provide evidence-based rationale for massage treatment. The practitioner should synthesize the research well and integrate it into their explanation of why the case is of scientific interest.

The writing should flow seamlessly between published ideas and practitioner ideas. It should be evident the practitioner thoroughly understood the research and directly applied it to the case study. No results or data from the case should be in this section. The last sentence/s of the introduction should state the objective, outcomes and measurement tools.


The methods section provides all the details necessary for another practitioner to duplicate the work. It includes the client profile and the treatment plan. The medical story should be explained comprehensively enough so the reader can utilize their own clinical decision-making.

This section includes a presentation of the client’s demographics, such as age, gender and occupation, medical history and diagnosis, including what kind of professional arrived at the diagnosis and if applicable, include information or findings from other providers about the client’s condition. Prior treatments should be explained clearly, specifically the client’s experience with massage for the condition.

The practitioner should include massage contraindications, whether the client has consulted with or informed their doctor about receiving massage if under direct medical care, and a description of the client’s desired outcomes.

Outcomes & Assessments

The outcomes and assessments section should include any information from a health care practitioner who can perform diagnosis. How, when and where the assessments were taken should be clearly stated, as well as what measurement was chosen, why it was chosen and what was specifically measured.

The use of standardized assessment measures established in the literature is preferred. The assessments chosen should make sense for the presenting condition. The outcomes (at least one) should reflect the client’s goals and may be function-related, such as total hours sewing without pain.

The practitioner should describe relevant findings from the assessment, such as postural analysis, visual observations or range of motion. Assessments should be supported by literature, make sense for the presenting condition and be tied to the client’s goals. The practitioner should describe the training they received to be able to use the assessment approaches or tools. Clinical findings should be tied to the treatment plan rationale.

When describing the intervention, the author should also explain their background and the environment where massage was performed. The intervention needs to be clearly described, easy to understand and easily replicated.

Description should include intervention/s, number of treatments, duration, frequency and anatomical location/s of massage application. Applied techniques should be evidence-based, safe for the condition, involve clinical decision-making and be supported by the literature and clinical decision-making.

A crucial component of the treatment plan is the practitioner’s rationale for the particular massage or bodywork technique/s used:

• Treatment choices must be supported by the therapist’s scope, training and references to the available literature and safe practice guidelines.

• If there are no direct references to massage therapy for the condition, the author should indicate why the treatment approach was chosen based on an understanding of how the condition typically presents and how it presented in the client.


The results section presents the results of the intervention but should not attempt to interpret their meaning. Data should be presented in an organized and easily understandable manner; typically, raw data should not be presented. Practitioners are encouraged to succinctly present findings in either a table or graph format. The outcomes should be presented in the same order they’ve been introduced, and no new outcomes should be presented here.

Note that data should be presented only once. If a table or figure is presented it should be clear, organized and accurate. Graphs should have appropriate labels, including a chart title and axis titles; the graph’s range should match the assessment range. The written portion of the report must refer to any table or figure, if presented. Include how the client tolerated and followed the treatment plan and how this was monitored.

It is important to include the patient’s voice and thoughts on treatment/s and outcome/s, which can strengthen the report. Comments and quotes from the patient in the discussion section allow them to be heard about their experience. The practitioner should state whether there were any adverse or unexpected events.


The discussion section provides an opportunity to summarize and evaluate the outcomes of the treatment process. It is also important to integrate the findings from the case into the body of literature that currently exists on the topic.

Therefore, this section should start narrowly and end broadly; interpret overall findings clearly and concisely; not include raw data; restate the objective and relate findings back to the objective; and explain how findings add to the literature and relate to the client’s goal/s. Findings should not be overemphasized or described as “significant” or “proven.”

Only the outcomes presented in the results section should be discussed. The practitioner should speculate on why the treatment/s had an effect or not. The limitations of the process should be clearly discussed, including problems with methods and any abnormalities in the data. The author should explain future implications for practice and make suggestions for future research.

The Abstract

Although the abstract is the first section of the case report, it is usually written last. The information in the abstract should mirror the information in the body of the paper.

The abstract summarizes the key findings and conclusions of the report and is structured to include the following sections: background or introduction, objectives for the case report, case presentation (abbreviated client demographics, brief health history, diagnosis), assessment measures, treatment/s, practitioner’s background, results or findings and discussion.

You Can Write a Case Report

The Massage Therapy Foundation is reopening its annual Case Report Contest to practitioners. The deadline is June 1 each year. Review a free recording about case reports from an Information Session Webinar at to learn more and earn one free CE.

Writing a case report is a valuable experience that can contribute to knowledge and improve client care. It is essential to follow ethical guidelines and reporting standards to ensure the report’s quality and accuracy. With hard work, patience and a growth mindset, anyone can write a case report.

Robin Miccio

About the Author

Robin Miccio, LMT, CEIM, is a massage therapist and program manager of the Integrative Health Program at Children’s Hospital of Philadelphia. Shortly after graduating from massage school, Robin wrote a case report that received an award through the Massage Therapy Foundation (MTF; Case Report Contest. Miccio is a former MTF trustee, currently chairs the contest review committee and enjoys reading other therapists’ case reports. Miccio wrote this article on behalf of the Massage Therapy Foundation.