In many cases the sequence of events in a health care massage is the same as in a wellness massage, as discussed in detail in Chapter 10, Topic 10-1 (Overview of a Wellness Session). Described here are the events that do not occur in a wellness massage but are specific to health care massage. Every situation is different, however, and every session will not follow this exact sequence. For example, a client in a hospital receiving massage for condition management might not benefit from the findings of a posture and gait assessment. These issues are discussed further in Topic 19– 5 (Treatment Planning for Health Care Sessions).

Box 19-1 outlines the events in a general health care massage most often related to a soft-tissue injury. The greeting, the tour of the facility, and the aspects of the interview related to policy and procedures, ruling out contraindications, and client expectations are often the same as in a wellness session. Clients still fill in paperwork, but the health history form is likely to be more comprehensive, and other intake forms such as a pain questionnaire might also be used, as described in upcoming sections. Health care sessions focus primarily on functional limitations, setting functional goals, and massage treatments that will help the client return to full function. Physical analysis such as a posture and gait assessment and range of motion assessment are conducted before finalizing the treatment planning process and transitioning into the massage. After the massage the therapist conducts a post-massage physical analysis that may include a posture, gait, and range of motion assessment. The pre- and post-assessments can be compared to explore the effectiveness of the massage treatment. The therapist may also want to suggest client self-care activities, such as the application of a hot pack or specific stretches to use between sessions.

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Aspects of Health Forms Specific to Health Care Massage

The health intake form for health care massage (Fig. 19-1) is generally longer than a form for wellness massage. With a wellness massage, the client may come once a month for relaxation or come to a clinic once while on vacation in the area and never return again. With health care sessions, however, the therapist is likely to work with a client regularly in an effort to achieve treatment goals over many sessions. You are also more likely to interact and share information with others on the client’s health care team. The form shown here is one example that works well. You can adapt forms or create your own to best address the types of health care massage you offer.

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The first section of this sample health care form is like that of a wellness form and gathers general contact information. The second section gathers information about the client’s health care team. The client might list contact information for a physician, physical therapist, chiropractor, psychologist, acupuncturist, traditional Chinese medicine doctor, or other health care provider who manages the client’s condition or symptoms. Recall the release of information form discussed in Chapter 6 (Ethics and the Law). Clients must give their permission for their health information to be shared with the other health care providers on their teams.

On the second page of a typical form the client prioritizes current health concerns and notes the severity of symptoms (mild, moderate, or severe) and whether they come and go (intermittent) or are felt constantly (constant). The client describes the activities that aggravate the symptom and make it worse, and any activities used to relieve symptoms. If clients wish to list numerous health concerns supply them with additional pages.

Functional limitations are daily activities that are limited by a condition or symptom. A client lists these limitations on page three of the sample form shown here and described self-care routines used to decrease symptoms. It’s not uncommon for clients to lose the ability to do small tasks that have great meaning to them, because of an injury or the onset of a condition. For example, Sarah, a 62-year-old grandmother, could pick up her grandchildren and carry them around without limitation before she was in a car accident. In the accident she sustained a whiplash injury and now can’t lift her grandchildren, even once during a day, without her neck pain increasing from mild to moderate. After any lifting, her neck pain persists sometimes for two or three days and is relieved only by warm packs and pain medication. Sarah’s primary goal is to be able to lift her grandchildren without increased neck pain. Knowing this functional limitation and the importance of Sarah’s grandchildren in her life will help you focus on treatment goals that address Sarah’s neck pain.

Page three of this form is also used to gather information about medications, past surgeries, injuries, and major illnesses. Like page two of the wellness form, page four of the health care form provides a broad overview of a client’s medical picture and is signed and dated by the therapist.

Overview of a Health Check-In Form

A health check-in form (Fig. 19-2) is used by some therapists before every health care massage session to get an up-to-date picture of a client’s symptoms, the severity of symptoms, and any limitations the client is experiencing in activities of daily life. This form may also reveal improvements or setbacks from the previous session. You could use a health check-in in a written format as shown in Figure 19-2, or you could use a form that allows clients to quickly chart their symptoms on human figures (Fig. 19-3).

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Human figures may be used by clients to show a pictorial representations of their symptoms or by therapists to document visual and palpation findings. This form is different from that used in a wellness session. The client draws circles around areas where they experience a symptom, indicates the type of symptom with a letter, and notes the severity of the symptom experience with a second letter. Pain in an area is noted with a P, while joint or muscle tension is noted with a T, and numbness or tingling is noted with an N. If the symptoms are mild, an L is used (to denote low pain, tension or numbness); moderate symptoms are indicated with an M, and an S indicates severe symptoms. Other ways of indicating symptoms and severity might also be used. The client is asked to describe any current functional limitations.

One benefit of this type of documentation is that it is quick and easy to use and simple to read. If clients are asked to document their symptoms on human figures before every session, the therapist can tell at a glance if the client is making progress. The number and size of circles should decrease and the symptom ratings (L, M, S) should be lower. Fewer functional limitations should be listed. This type of documentation also shows if the client is getting worse or developing new symptoms. Over time, these forms provide invaluable information for treatment planning.