Treatment planning is the documented process of developing a client’s treatment or course of treatment. The resultant treatment plan consists of strategies the therapist will use to resolve issues and address goals identified by the client. The plan also takes into account the therapist’s training, experience, and scope of practice. A well-designed treatment plan will be individualized for every session, with client safety the first priority.
Treatment planning takes into account the client’s therapeutic goals or reasons for seeking massage therapy, his or her current health status, information gathered on a completed intake form, answers to questions asked by the therapist, palpation assessments of tissues, and visual assessments such as range of motion, gait, and posture if applicable.
If your client has any of the following health changes, recommend that he or she discuss the situation with a qualified health care provider. The list represents signs and symptoms of an underlying pathologic process.
- Unexplained weight loss
- Abnormal bleeding from any orifice
- Unexplained inflammation
- Shortness of breath
- Unexplained persistent fatigue
- Changes in body function (sleep, eating, bowel, etc.)
As you can see, treatment planning may involve working with a health care team. Let us look at steps taken to develop the treatment plan.
PPALM: Assessment Domains
An assessment is an evaluation of something that helps form professional judgments. Using assessment domains ensures therapists gather the information needed to determine the best manual approach or approaches to use to fulfill the client’s goals. PPALM assessment domains also give an organizational framework to the interview that helps prevent errors of omission.
PPALM is an acronym for the first letter of the five assessment domains:
- Purpose of session
- Allergies and skin conditions
- Lifestyle and vocation
- Medical and surgical information
Ideally, each domain is discussed with the client during the interview. Information gathered is listed on the PPALM treatment planning form or on the back of the client intake form. Even though some information requested is listed on the client intake form, you will reexamine the information during the interview even if the comment is, “Mrs. Brown, are there any health conditions that would affect your massage today?” If there is nothing to report in a particular domain, place a null symbol (Ø) in the corresponding space to indicate that there was nothing to report instead of leaving it blank. This will indicate that the domain was discussed with the client.
The length of time and depth of the interview are determined by the session’s purpose, which is one of the first questions you ask the client. Because massage therapists have a broad practice spectrum ranging from wellness to rehabilitation, information within each domain will vary from general and nonspecific to detailed and precise. Download a copy of a PPALM chart HERE.
It is essential to find out your client’s purpose for seeking massage therapy. This is the most important element of the treatment plan.
Find out what needs to be achieved today. Is it pain management? Relaxation? A combination of the two? Begin with an open-ended question, such as, “What is your primary goal for today’s session?” If this question does not elicit an answer, use a more direct or close-ended question, such as, “Do you need pain relief or stress relief today?” These questions go a long way toward determining your client’s primary purpose or therapeutic goal. This is also a good time to discuss previous massage experiences your client has had with other therapists.
Pain is one of the most common symptoms prompting clients to seek massage therapy services. According to the 2015 consumer survey conducted by the American Massage Therapy Association, over half (56%) of clients who receive massage therapy are looking for pain management or similar “medical” reasons. Although pain is one of the body’s most important protective responses, it is very complex and no longer described as simply a response to injury. To help you better understand the client’s experience of pain, ask questions related to the acronym OPPQRST. OPPQRST stands for the following:
- Onset—ask “When did it start?”
- Provocative—ask “What makes it worse?”
- Palliative—ask “What makes it better?”
- Quality—ask “How would you describe your pain?”
- Radiation—ask “Does the pain radiate?”
- Site—ask “Where does it hurt?”
- Timing: Ask “How often does it hurt?”
Provocative pain may be explored further by asking “Does it affect your work, sleep, or recreational activities?” “Does it hurt more during movement, during rest, or when you feel anxious?” Timing may be explored further by asking, “Does it hurt more first thing in the morning or at the end of your day?” “How long has it been there?” “Is it there all the time?” These types of questions will give the therapist clues as to whether pain is related to physical stress, psychosocial stress, or sustained body postures while sitting or sleeping.
Information about the client’s pain will help you decide which areas should be focused on, which areas should be avoided, which techniques to use, or whether the massage should be postponed. If your client indicates that his or her pain is associated with a motor vehicle accident or work-related injury, ask if he or she is involved in an immediate or impending lawsuit. These situations may require special client documentation and billing procedures.
Allergies and Skin Conditions
Inquire about environmental, product, or food allergies your client may have. If yes, ask about past allergic reactions. If the client mentions that he or she has had a severe allergic reaction, ask if the client is carrying an epinephrine autoinjector, such as an EpiPen, and where it is located in case it is needed.
Ask about allergies to latex, wool, nuts (may be and ingredient in massage lubricants), or plants (may affect essential oil use). If your client is allergic to latex or wool, he or she may have an allergic reaction to shea butter or lanolin, respectively. Latex allergies have been linked to allergic reactions to shea butter because of cross-reactivity (Grier, 2012). In these cases, massage lubricants containing these ingredients should be avoided. A hypoallergenic lubricant is recommended in these cases.
Ask your client about skin conditions. Skin conditions that are not bothersome (eg, psoriasis and eczema) may be overlooked on the client intake form. Noncontagious skin conditions often can benefit from lubricated massage if the affected skin is not broken.
Be sure to assess your client’s skin. If you find areas of swelling, redness, bruising, lacerations, foul odor, excessive heat, or other abnormalities, bring it to your client’s attention, make note of it in your client record, and factor it into your treatment plan.
Lifestyle and Vocation
The lifestyle and vocation domain explores how your client uses his or her body throughout the day. Find out about your client’s occupational history, leisure sports or hobbies, and regular physical activities. Investigate postures used while sitting or standing, as well as body positions used while lifting heavy objects, if applicable.
Ask about sleep patterns and postures. Answers to these questions may uncover potential areas of muscle tension or trigger points. Be sure to consider your client’s age, and psychosocial influences such as work, relationships, and home life. If a client indicates a high level of stress, your treatment plan might include relaxation massage. You might include stress-reduction activities as part of a home care plan.
Articles and Journal Referenced:
- Salvo, S. G.: Mosby’s pathology for massage therapists (5th ed.). Elsevier/Mosby.
Susan Salvo is a board certified massage therapist with 30+ years of experience. Susan is passionate about massage therapy and massage education. You can contact her at firstname.lastname@example.org.