Medical Conditions in Massage Practice: Intake Forms and Questions, Parts I-III
By Tracy Walton, LMT, MS
Tracy Walton, LMT, MS, consults to hospitals and massage schools,
and teaches "Caring for Clients with Cancer" courses offered
nationally for massage therapists. She was named AMTA Teacher of
the Year for 2003, and is currently working on a textbook, Medical
Conditions in Massage Therapy. She can be reached through her Web
site, www.tracywalton.com, which includes current research and
resources on cancer and massage .
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.
Thanks to better training and texts in the field, massage therapists tell me their knowledge of
contraindications is growing. But many report gaps in knowing how to interview for contraindications and
how to apply the answers in the session....The task of interviewing clients for contraindications feels easy
for some therapists, harder for others. Some tell me they rush through it to get to the hands-on session;
others like to take their time. The massage setting can also influence the interview. In private practice, we
have as long as we are comfortable scheduling with the each client. Many therapists allow an extra 15
to 30 minutes for a first-time session. In contrast, most spa and other high-volume settings (on-site,
sports events, fundraising walks, etc.) allow for very little information gathering. Years ago I worked in a
spa where we were taught to limit our intake to one question on the way from the greeting area to the
treatment room: "Is there anything I should know about your health?" Many spa practitioners tell me this is
still the limit of their questioning. The problem with this question is that clients don't usually know what
we're looking for or which health conditions are important to massage therapists. Indeed, some frustrated
massage therapists tell me that they don't always know what they're looking for either. Our pathology and
clinic training doesn't always prepare us for gathering information quickly, easily and thoroughly in a
range of massage settings. From massage therapists I meet around the country, I am learning that given
lists of contraindications, massage therapists don't always know how to interview for them. Given lists of
interview questions, we are not necessarily taught how to use the answers.
As the profession develops, we will grow to understand our interviewing tasks more fully and be able to
adapt them to the special challenges of different massage settings. I am confident that we will standardize
brief, efficient interviews and protocols for higher-volume settings and more extensive intake practices for
other settings. For now, here are some "umbrella" questions to ask every client, which should be added to
any interview regardless of the setting in order to get a good health picture and design an appropriate
massage for each person.
Are you currently (or have you recently been) in a
For those in high-volume settings without forms or
record keeping, this is a question to ask on the way to
the table. Even if your setting allows forms and ample
interviewing time, ask this of everyone. If your intake
form includes a list of specific conditions, this is a good
all-purpose question to catch any that are not listed. It
might prompt a client to remember something he/she
forgot to mention elsewhere on the form. Then you can
apply appropriate massage contraindications. This
question leads to the first, most obvious follow-up
question: "For what condition or complaint have
you been seeing them?" Here you are looking for the
diagnosed condition to determine massage contraindications and for the complaint that may have brought
the client to the physician in the first place. For example, suppose a client has chronic acid reflux or
constipation for which she is seeing a physician. If there are no specific questions on your form about
digestion and elimination, the physician question may capture this. Reflux might dictate a change in the
massage position - a surface slightly inclined toward the head - or bolstering in the side-lying position.
Constipation, depending on the cause, may indicate reflexology or acupressure techniques, or even
gentle abdominal strokes or contact. Another, broader follow-up question might be, "Are you
seeing any health practitioner regularly?" to spot conditions the client may be bringing to a
chiropractor, acupuncturist or movement practitioner, for example. Here you might find out about his/her
acupuncture treatment for headaches, dental treatment for TMJ, or chiropractic treatment for a chronic
low-back injury. Answers can lead to collegial conversations with these professionals and to proper timing
and coordination of treatments.
I know acupuncturists who ask their clients to let acupuncture "sit" for a day or two before following with
other treatments such as massage. Massage therapy can be a useful adjunctive therapy for TMJ. The
chiropractor would benefit from knowing the massage therapist's approach to the client's low-back issue.
And in each of these cases, there might be contraindications or indications to massage therapy
depending on the cause of each condition. If a number of diagnoses are possible, massage should be
tailored to the most conservative of these: If doctors are looking at either arthritic changes or bone
metastasis as a cause of pain in the low back, treat the area as though bone metastasis were the cause
and avoid pressure and joint movement in the area until proven otherwise. "What kind of diagnostic
procedures are you undergoing (have you recently undergone)?" is another direction to go. The
diagnostics question is useful for several reasons. It tells us what the client's other health care providers
are concerned about: tumor as a cause of headache; fibroids as a cause of low back pain; stress
aggravating stomach ache. This information is useful without memorizing lists of diagnostic tests. Instead,
ask the client what is being investigated, and why. While some clients are more knowledgeable about
their care than others, this question may yield clear contraindications or indications to massage. Massage
therapists don't necessarily need to go to nursing school or medical school to understand their
clients' medical status - they just need to figure out what other care providers are concerned
about, then investigate their own field for any adaptations for massage. Finally, a compelling
reason to ask about a client's diagnostic procedures is simple interest in the client's life. Put simply,
diagnostics are stressful. Sometimes painful, often requiring awkward positioning or holding still, some
procedures aggravate muscle tension that we may be well equipped to relieve once we've followed
suitable precautions. The long wait between test and result can be difficult, depending on the nature of
the test and possible diagnosis. Our clients' experiences of their medical care can tell us not only where
to avoid massage but also where to focus it and how to listen. I once worked with someone who had an
MRI for a knee injury the day before. She was awaiting word on whether to have surgery. The MRI was
hurried and the technician neglected to tell her when the test was starting. It began before she was
comfortably positioned, and she had to hold perfectly still for 20 minutes. Already frazzled, this experience
left her more worn out with tension in her hips and low back. The wait for the doctor's call was an anxious
time. Careful massage of tense muscles and a listening ear helped her cope as she waited for word on
her immediate future. We handle the human body with care and attention, but we also interview
with care and attention, which is as therapeutic as our hands-on services. We ask about another's
experience of their body. Questions about their health care tell us something about the texture of our
clients' days. These small questions ask, "What is it like to be you?" which can, in and of itself, be
healing. A client's answers are as useful to our massage design as our own palpatory cues. At the same
time, they can deepen our understanding and the compassion we bring to our work.
Thanks to better training and texts, massage therapists tell me their knowledge of contraindications is
growing. But many still report gaps in knowing how to interview for contraindications and how to apply the
answers in the session....
"Are you taking any medications?"
Now let's turn to a third all-purpose intake question, which follows
the second question nicely: "Are you taking any medications?"
Along with a few follow-up questions, this question yields useful
information during an intake. Unfortunately, the information in this
territory can seem cryptic: drug names are notoriously foreign-
sounding and long (amoxicillin, amitryptiline), sound similar (celexa,
celebrex, cialis), and many of us misspell them. The good news is
that massage therapists can use information about meds without
having to go to pharmacy school. By asking a few follow-up
questions for each medication and doing a little investigation, we
can determine which massage contraindications or modifications to
use. Below are some follow-up questions with some examples of
how the MT might use the answers.
How do you spell that?
Correct spelling may come from the client or a little more
investigation. Correct spelling is key to looking up a medication -
perhaps not in the moment, but at some point for your learning. If the client can't provide the correct
spelling ("It's those little yellow pills" or "The ones I use for thyroid"), it's still possible to get the needed
information. But at some point determine the closest spelling possible. Search engines on the Internet
can be quite forgiving with less than perfect spelling. For example, suppose you have a client with
Crohn's disease on a medication that neither of you can spell correctly. If you type in "methatrexate" or
even "methatrexate Crohn's disease," Google will return a kind message to you: "Did you mean
methotrexate?" There are numerous sites about medications. One I use is www.drugs.com, which lists
consumer information alphabetically by drug. Many drugs also have their own Web sites, including
coumadin.com or prednisone.com. These sites have general information about the drug, including why it's
prescribed and side effects.
What is the medication for? What is it designed to do?
This may unearth a medical condition to ask more about, especially if the condition affects tissue or organ
function. Bringing it to light, the MT may need to follow contraindications for the condition itself. Suppose
a client lists medications for hypertension and heart disease. The medication may not resolve the problem
entirely but may just control it, and the disease is still present. Hypertension or heart disease could
require modifications in client position, pressure used on the legs in case of a risk of blood clots
(DVT), and other modifications. If the condition itself puts someone at risk for stroke, the massage
therapist should not use pressure near the carotid artery or on any pulse points. If the client is taking
ibuprofen or aspirin for the pain of an unstable injury, treat the area as unstable and avoid stretching or
other strong passive movement in that area, and refer the client to his/her physician. Stronger pain
medications, such as narcotics, interfere with perception and the ability to give the MT feedback about
pressure. The practitioner should only use gentle pressure and joint movements to avoid causing injury.
Self-medication is vital information that comes from asking this question. Upon finding out that a client
self-medicates for musculoskeletal pain, sleeplessness, headaches, etc., the massage therapist should
suggest (sometimes strongly) for the client to see a physician or other health care provider for diagnosis
and additional help.
Is the medication effective?
This question gets at over- or under-treatment, and there is some overlap with the question above. If a
medication is not effective in reducing blood pressure, for example, treat the client as if he/she has high
blood pressure and investigate massage contraindications accordingly. If a medication is good at
preventing blood clots it will probably cause easy bruising, so lighten the massage pressure. Coumadin, a
blood-thinner (anticoagulant), is one such medication. It is commonly presented as a massage therapy
contraindication, but only one element of massage - pressure - is contraindicated. Use follow-up
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