Medical Conditions in Massage Practice: Intake Forms and Questions, Part I
May 29, 2009
Medical Conditions in Massage Practice: Intake Forms and Questions, Part I
May 29, 2009
Whether massage therapists call it "medical" massage, "therapeutic" massage, or "relaxation" massage, we work with people with many complex medical conditions. No matter which setting we work in - spa, private practice, sports or medical settings - we see a range of health conditions that ask us to investigate appropriate contraindications.
In this three-part series, I'd like to offer my thoughts on interviewing for those contraindications. The purpose of this series is twofold: to support therapists in their work with people and to invite dialogue in the field. I'll begin this installment with observations of the intake process for massage therapists then offer a sample question for the health history. Each subsequent article will feature one or more health history questions and ideas for how to use the client's answers.
In my work with therapists with different backgrounds and working in different settings, I've discovered a common theme: most are much more comfortable providing the massage than interviewing clients for contraindications. When I ask why this is, most tell me the language of their hands is their chosen language. After using my hands for 15 years in massage practice, I must agree. My hands engage in wordless, soundless and sometimes sacred exchanges with clients. The interview, in contrast, can seem like mere business.
But massage therapists tell me there's more to this than a simple preference for hands-on work; most say they did not get solid schooling in conducting an intake interview. The most acute gap for many of them is in interviewing for medical history. Fifteen years ago when I graduated from massage school, we could purchase commercially available, preprinted health history forms for massage therapy. I remember them on heavy paper, four pages, lists of medical questions, and questions about diet and nutrition, all very comprehensive. I suspect the form was borrowed from a medical setting, as many of the questions were way out of the scope of the average massage therapist. Still, seeing little else in the massage literature, I dutifully purchased a stack of them to begin my practice.
There was a small problem with this approach: I had not the slightest idea how to use them. I knew how to ask the battery of questions on the form, but I didn't know what to do with the answers. How would it change my massage to know that my client followed a certain diet, that he drank four to six alcoholic beverages per week, that she had had most of the common childhood diseases, that there was a family history of heart disease? In a nostalgic mood recently, I dug the form out of cold storage and marveled at its length. I can't believe I got through so many interviews without being asked, "Why are you asking me this?" before I switched to designing my own intake forms.
Mind you, I had graduated from a strong, two-year massage therapy program with many hours of training in hands-on work, communication skills and the sciences. The profession shared my interviewing uncertainty. In 1990, literature about massage contraindications was scarce. We had little shared understanding of what we had to know to massage safely, and a few alarmist stories about someone who had done something in a session somewhere and the client got sick afterward. We relied on this lore in the field, a very basic understanding of the body, and our wits to keep our clients safe and ourselves out of trouble.
Changes in the profession have made it much easier to identify client problems that we need to act on, avoid or treat with caution. Ruth Werner took our uncertainty in stride and produced A Massage Therapist's Guide to Pathology1 the first widely available text from which we could finally draw some links between health conditions and massage contraindications. Many other useful texts appeared as well, including books on medications and massage,2,3 other rich pathology texts, and even some texts for massage specialties, such as massage in the hospital setting.4 Articles are appearing on work with a wide range of clients. Together we're getting our feet under us about individualizing massage for clients in all states of health. Together we're figuring out the information we need to practice safely.
But we still need to work on how we gather that information without interviewing the client all afternoon. What is important to ask about a client's health? And, more importantly, how do we use their answers in massage design? How do we find out what we need to know in a brief interview format? How do we follow-up on clients' answers?
I have designed intake forms for my own practice, a massage school with a large clinic, and a training setting where we run one-time clinics for clients with cancer-with some medically complex individuals. I have seen countless intake forms in the literature and at the schools I visit. There are some basic, all-purpose questions that bear asking. In this series of articles I will focus on a few of them: "What is your activity level and the kinds of movement you do during the week," "Are you taking any medications," and "Are you currently in a physician's care?" I will also propose how to use our client's answers to these questions.
What is your activity level? What are the types of activities you engage in during the week?
This question often elicits a guilt response: "I should be going to the gym more"; "I'm afraid I'm something of a couch potato"; or "I'm at a desk all day." But it still can lead to valuable information for massage therapy. First, it can lead to tension patterns produced by a client's activities. This conversation can go a number of useful places. Chronic telephone use: which ear? Chronic neck and shoulder tension on that side. Massage with focus on the neck, attachments at the occiput, shoulders and lateral pecs. Massage therapists know where to find these tension patterns and ease them. Questions like this provide an early tip-off to where the session might go.
Questioning about activity and movement can be helpful in other ways, too. For an elderly client, one with a systemic illness or in strong medical treatment, the activity level can help a therapist assess how well the client can tolerate massage. For example, in general, it is important to work conservatively with people in cancer treatment, starting with gentler work. It may be advisable to introduce stronger massage in small increments over weeks of monitoring the client's response. The activity level of the client can help you assess where to start and when to add increments.
One client in her late forties has been in ongoing treatment for metastatic breast cancer for several years. She has been building a deck, clearing her land, cycling long distances. Another client has pancreatic cancer and is in strong chemotherapy. She is 83, and beginning to find the stairway to my office a challenge. Both require specific massage adjustments to their treatments for complications such as lymphedema risk, bone metastasis, and several other factors. But the first client, after taking those into account, may tolerate a reasonably vigorous massage and benefit from it.
The second, older client, clearly weakened by complications of her disease and in strong treatment, requires a gentler session. Tolerance of exercise can be used in assessing tolerance of massage therapy. Activity levels provide useful data for the massage therapist who can then change the length of the session, the pressure used, or even how gently or vigorously to stretch or range a joint in a session. A more customized session is then possible, rather than a single protocol for a client who checks "yes" in response to the question about cancer history.
The activity level and the types of activities are useful information for the massage therapist. Answers to these questions can provide key information quickly. This is especially important in high-volume massage settings with limited time for interviewing and documentation. Interviewing has its challenges, but we've come a long way from preprinted forms and our empty, uncertain use of them. As the profession continues to develop and we share more information with each other, the process of interviewing will become clearer and easier for us all.
Editor's note: Look for part two of Tracy's series in the July 2005 issue.
- Werner, Ruth. A Massage Therapist's Guide to Pathology (2nd ed). Philadelphia: Lippincott Williams & Wilkins, 2002. Expect a third edition soon.
- Persad, R. Massage Therapy and Medications. Toronto: Curties-Overzet Publications, 2001.
- Wible, Jean. Pharmacology for Massage Therapy. Philadelphia: Lippincott Williams & Wilkins, 2005.
- MacDonald, Gayle. Massage for the Hospital Patient and Medically Frail Client. Philadelphia: Lippincott Williams & Wilkins, 2005.