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CLINICAL ASSESSMENT FOR
MASSAGE THERAPY
CLINICAL ASSESSMENT FOR
MASSAGE THERAPY
A Practical Guide

David Zulak MA RMT

Foreword by Sandy Fritz BS MS LMT Board Certified
NCBTMB
HANDSPRING PUBLISHING LIMITED
The Old Manse, Fountainhall,
Pencaitland, East Lothian
EH34 5EY, Scotland
Tel: +44 1875 341 859
Website: www.handspringpublishing.com

First published 2018 in the United Kingdom by Handspring Publishing

Copyright © Handspring Publishing 2018

All rights reserved. No parts of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without either the prior written permission of the publisher or a licence permitting
restricted copying in the United Kingdom issued by the Copyright Licensing Agency Ltd, Saffron
House, 6–10 Kirby Street, London EC1N 8TS.

The right of David Zulak to be identified as the Author of this text has been asserted in accordance with
the Copyright, Designs and Patents Acts 1988.

ISBN 978-1-909141-37-7

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloguing in Publication Data

A catalog record for this book is available from the Library of Congress

Notice
Neither the Publisher nor the Authors assume any responsibility for any loss or injury and/or damage to
persons or property arising out of or relating to any use of the material contained in this book. It is the
responsibility of the treating practitioner, relying on independent expertise and knowledge of the
patient, to determine the best treatment and method of application for the patient.

Commissioning Editor Mary Law

Project Manager Morven Dean
Copy-editor Stephanie Pickering
Designer Bruce Hogarth
Indexer Aptara, India
Typesetter DSM, India
Printer Bell and Bain, UK
 The
Publisher’s
policy is to use
paper manufactured
from sustainable forests
Dedication

This textbook is dedicated to my wife, Anne Wilson.

Without her support, love and inspiring example of determination, this book
would never have seen the light of day.
It is also dedicated to my extraordinary children, Katie and James, for their
sustaining love.
Contents

Foreword
Acknowledgements
Preface
Introduction
Common Abbreviations

PART I: Essentials of Assessment

1 Assessment matters
Assumptions can be misleading
What do we think we are doing?
Assessment is like drawing a map
Assessment as the basis for being able to treat
Being a detective
Isn’t imaging technology better than manual assessment?

2 Impairment model
Assessment versus diagnosis
Impairments as impaired tissues or functions
Impairment model for clinical assessment
Impairments and treatment plans
Why we need to be competent at clinical assessment
Some general guidelines for assessment
Review of what clinical assessment means for massage therapists

3 Assessment protocol
Brief overview of assessment protocol
Comments
Intake: forms, interviewing and case history taking
A short history of pain and impairment
Terms patients use and what they may imply
Interviewing the patient
Observations
 Rule outs
More on range of motion testing
Special tests
Comments on ROM testing
Assessment and treatment plan
Impairments and treatment plans
Charting and reporting
Chapter appendix: Assessing joint play with joint mobilization

4 Understanding pain
The pain gate theory
Terminology and definitions
Listening to the tissue: how pain speaks to us and what it might be saying
Conclusion

5 Postural assessment and gait

Muscle balance and posture
General postural examination
Gait analysis

6 Spinal motions: structure and function

The living spine
Considerations

PART II: Regional Assessment

7 Ankle and foot
Clinical implications of anatomy and physiology
Case history (specific questions)
Observations
Rule outs
Range of motion testing (ROM)
Special tests
Specific ROM testing of the toes

8 Knee
Clinical implications of anatomy and physiology
Case history (specific questions)
Observation and inspection
Rule outs
 Range of motion testing (ROM)
Special tests

9 Hip and innominate

Clinical implications of anatomy and physiology
Case history (specific questions)
Observations
Rule outs
Range of motion testing (ROM)
Special tests

10 Comprehensive examination of spine

Comprehensive structural examination of the spine and pelvis
1. Standing postural views
2. Checking symmetry of landmarks
3. Checking symmetry during AF-ROM
4. Assessing postural stability
5. Checking postural symmetries and AF-ROM while sitting
6. Checking postural symmetries while supine
7. Checking rotation in the body
8. Checking landmarks prone

11 Sacroiliac joint and pelvis

Note to the reader
Chapter organization
Section 1: Clinical implications of anatomy and physiology
Section 2: Innominate motions and impairments
Section 3: Testing for innominate impairments
Section 4: Introduction to sacral dysfunctions
Section 5: Testing for sacral dysfunctions
Section 6: Orthopedic assessment of sacroiliac joints and pelvis
Chapter appendix

12 Lumbar spine
Clinical implications of anatomy and physiology
Case history (specific questions)
Observations
Comprehensive examination of the spine
Rule outs
 Range of motion testing (ROM)
Active free range of motion (AF-ROM)
Motion testing for facet joint dysfunctions in the lumbar spine
Passive relaxed range of motion
Resisted isometric testing and strength testing
Special tests

13 Thoracic spine and ribs

Clinical implications of anatomy and physiology
Comprehensive examination
Case history (specific questions)
Observations
Range of motion testing
Thoracic spine neurological symptoms
Testing for group dysfunctions
Introduction to the ribs

14 Cervical spine
Clinical implications of anatomy and physiology
Comprehensive examination
Case history (specific questions)
Observations
Rule outs
Range of motion testing (ROM)
Special tests
Introduction to specific neurological testing
Temporomandibular joint (TMJ) testing: an introduction
Assessing the TMJ
Motion palpation of the lower cervical spine

15 Thoracic outlet
Clinical implications of anatomy and physiology
Case history (specific questions)
Observations prior to specific TOS testing
Rule outs
Thoracic outlet tests
Upper limb tension tests (ULTT)

16 Shoulder
 Clinical implications of anatomy and physiology
Case history (specific questions)
Observations
Rule outs
Insight - why we need to test both sides bilaterally
Range of motion testing (ROM)
Special tests

17 Elbow
Clinical implications of anatomy and physiology
Case history (specific questions)
Observations
Rule outs
Range of motion testing (ROM)
Special tests

18 Wrist and hand

Clinical implications of anatomy and physiology
Case history (specific questions)
Observations
Rule outs
Range of motion testing (ROM)
Special tests
Chapter appendix A: Brief testing protocol of the hand and fingers
Chapter appendix B: Testing of the fingers and thumb

Appendices
1 Muscle chart
2 Joints: range of motion and tissues involved
3 Joints; capsular pattern, resting position (“open packed”) and close packed position
4 Neurological testing of nerve roots: upper extremity
5 Neurological testing of nerve roots: lower extremity
6 Testing of major peripheral nerves: upper extremity
7 Testing of major peripheral nerves: lower extremity
8 List of classic orthopedic tests

References
Further reading
Index
Foreword

To work with clients from an outcome goal process, it is necessary to be able

to gather information about the client’s health status. Physical assessment is
an important part of the information gathering process. The client history and
outcome goals will guide what physical assessments to perform. Physical
assessment can also help provide screening for referral, especially if joint
dysfunction is suspected. This book provides the information to learn a
variety of assessment skills to better understand the condition of the various
types of soft tissue and joints that may be related to the client symptoms.
Assessment seeks to understand not change. Assessment asks questions
and interprets the responses to those questions. Asking a client to move a
joint or hold against resistance are examples of the questions. The responses
can be normal function, limited function, function with effort and so forth.
We will not understand the client status without asking the questions first.
The assessment process is a skill. Too quickly we jump to interventions
with intention to change function. We press on this and pull on that before we
understand the bigger picture. I often identify massage therapists using too
much intervention and not enough assessment. This text is focused on
assessment. While guidance is provided toward choices for appropriate
intervention, an intervention is only used once assessment identifies the
conditions for a specific, unique individual and what outcomes for treatment
are desired.
There are many types of physical assessment procedures. For the massage
therapist, the ones used need to be effectively integrated into the massage
session process. There is an expectation about the massage session by most
clients. They want to lie on the table and be touched in a therapeutic way,
experiencing a sense of satisfying pressure and movement. There is value in
the general massage application. Performing too many physical assessment
tests will not feel like a massage to the client. You need to intelligently pick
and choose assessment methods. This text provides procedures to help you
learn about your client. Remember all aspects of the massage session are
assessment if you approach your client with mindful focus and pay attention
to their response to the massage application.

Sandy Fritz BS, MS, LMT Board Certified, NCBTMB

Founder, Owner and Head Instructor
Health Enrichment Center
School of Therapeutic Massage Lapeer MI
March 2018
Acknowledgements

There are many people to thank for helping me make this book become a
reality. I will begin by thanking all my students, who over the years taught
me so much, who were so patient with me, and who encouraged me to pursue
this project.
A large share of gratitude goes to Johan Overzet. Since meeting at the
Sutherland-Chan School of Massage and Teaching Clinic in 1992, we have
studied together, practiced our craft, debated, and advanced together. We
both attended osteopathic courses together in Canada and helped each other
survive the experience and be better manual therapists for it. The results of
many of our debates over the years are scattered through this book. Johan has
always been honest with me, whether in approval or criticism. That, above
all, proves he is the truest of friends.
I would like to thank Anne Wilson MA for her invaluable editing skills
over these many years. Also, I am indebted to Jackie Guanzon RMT and
Ashley Marcos RMT for their efforts in serving as proofreaders for various
parts of the book. Jackie also served as the principal model throughout the
book, assisted by Antonella Licata, Darryl Hoogendam RMT, Justin Doherty
RMT, Katrina Raney RMT, and Sara Hanson RMT.
I am grateful to my instructors at Sutherland-Chan School of Massage
Therapy for their dedication to the profession and to their students. I wish to
thank Debra Curties RMT and Trish Dryden MEd, RMT for their support and
encouragement in my first attempts at teaching, which also occurred at
Sutherland-Chan. My first co-teacher, the late Earl O’Neal PhD, RMT, who
so generously shared his wealth of experience with me, is fondly
remembered.

I am honored that Sandy Fritz MS, NCTMB has written the Foreword for
this book. I have been inspired by her dedication to the profession of massage
therapy, especially for her efforts over many years to improve the quality of
education available for students and practitioners.
Of course, I need to thank those at Handspring Publishing who worked to
bring this to print, including the publishers Andrew Stevenson and Mary
Law. I especially wish to thank Mary for her kind support, advice and gentle
reminders about deadlines over the last few years. Also, thanks go to Morven
Dean (Project Manager), Bruce Hogarth (Designer), Stephanie Pickering
(Copy Editor) and Hilary Brown (Marketing Manager); and to all those at
Handspring Publishing who had a hand in producing this book.

Thank you all

David Zulak
Preface

My wide range of experience both as a student and as a teacher, in many

different settings, from community colleges to universities and vocational
colleges, has, I believe, given me an unusually thorough and deep perspective
on, and understanding of, how to help others learn what they need to know
within a post-secondary educational setting. As a massage therapy teacher,
former program director and curriculum writer for schools of massage, and as
a facilitator of workshops for massage therapists in assessment and
techniques across Canada, I have listened to, watched, and learned from
students of massage: their learning styles, their typical or atypical educational
backgrounds, the life experiences they bring (or do not bring) to the
classroom, and the many different reasons that brought them to the point of
choosing this profession.
All of this experience and knowledge, gained over many years, has
informed this guide. The design and style of this book, its voice if you like, is
intended to help students learn the skills involved in assessment. It has been
specifically written for students of massage and those practicing massage
therapy. It is not meant to be academic, encyclopedic, or intimidating.
As a teacher faced with a student (or class) that performs badly my first
thought has always been “how did I fail to communicate to them what they
needed to know? How could I have taught this better? What else is it that
they needed to know in order to understand and become proficient at
assessment?” The answers to these questions built this book.
The book is deliberately written to be easily understood and therefore is
not written with a typically academic or jargon heavy style. It does, however,
include the proper terminology students need to know to continue their
studies and to communicate with other health professionals. I have not
written this book for academics or researchers, or for those who are already
highly proficient in assessment. I have written it to assist students of massage
therapy to quickly and efficiently learn the skills of assessment required of
them by their schools, the regulators of the profession, and their future
patients. Once they have learned what to do, how to do it, and why it is done
a certain way, then they can read further, and continue to learn more about
their profession or seek to specialize in treating specific types of patients,
such as athletes, maternity clients, elder care, and so on.

The book’s possible tendency to repetition, or “wordiness,” is deliberate

and intended to ensure that it includes all the information and clarifications
that I have, over the years, learned many, if not most, massage therapy
students need in order to learn the skills described. Further, I have seen over
and over again in my career as an educator that if the student understands
why they being asked to do something in a particular way rather than just
memorizing the steps in some specific musculoskeletal test, they are both
more likely to remember the procedure and (most importantly) will actually
use these skills in their practice once they have graduated. Therefore, I have
taken the time to fully outline the steps of each test and, when necessary,
show them in a series of photographs. (I feel that a student’s time is better
spent on learning and practicing their assessment skills rather than expanding
their reading comprehension skills!)

I have also provided, on occasion, some of the anatomical information

needed when trying to understand the structures being tested and thus, how
and why certain motions etc. are done in a certain way when doing a specific
test. If one understands the anatomy of a joint or tissue that needs to be
investigated, then the anatomy, the structure and function, of a joint or tissue
will help one to remember how to do a test. Assessment is thinking anatomy.
In other words, thinking through the implications of the structure and
function of a tissue is how the various elements of assessment were invented
or arrived at in the first place. If you actually forgot a test, or were never
taught it, a firm grasp of anatomy and the physiology of movement would
allow you to re-invent any musculoskeletal test, or maybe even create a new
and perhaps better test!

As I said earlier, this is a teaching manual designed to introduce and

provide the basics of the assessment skills required by our profession as
massage therapists. My hope is that this manual can achieve this goal without
traumatizing students so that when they have finished their training they will
not only retain and use this information and these skills but will be both
prepared and motivated to continue their learning of this essential element of
massage therapy. Along with all instructors in massage therapy, I hope that
our students come to realize it is only when they leave school that real
learning begins.

David Zulak MA RMT

Massage therapy practitioner, instructor and author
Paris, Ontario, Canada
December 2017
Introduction

Clinical Assessment for Massage Therapy has been created to do what its title
indicates, namely to help students of massage therapy learn the basics of
clinical assessment. It is a manual for practicing massage therapists to recall,
re-learn, or expand their assessment skills. It is designed specifically as a
learning tool.
This assessment guide is written by a massage therapist specifically for
massage therapists. Both students in massage therapy schools and those
already in the profession need a book written with them in mind in order to
help them be as effective and efficient as possible when treating injuries,
impairments, and dysfunctions and ensure that the application of techniques
and modalities remains both appropriate and safe for their patients.

The evidence base

A phrase often encountered when reading almost any written material in the
health care professions is “evidence-based practice.” In general, this evidence
comes from three main sources: research, clinical practice, and client/patient
values. Some authors consider that all sources of evidence should be valued
equally while others prefer a hierarchy of values where research (especially
double-blinded studies) rules supreme. I must disclose that I am of the former
opinion, that evidence from a number of sources should be valued equally,
especially within a manual therapy such as massage.
My principal reasons for not accepting research alone as the “gold
standard” of evidence for manual therapies are, very briefly, as follows.
When blinded research is being done on pharmaceutical medication, for
example, the variables of the principal effective agent can be tightly
controlled, as can the comparison agents (such as a placebo, or control group
receiving no treatment). However, where manual therapies are concerned the
variables around a technique or manipulation (for example) being
investigated become very difficult to control. If a variety of agents/therapists
are used (“inter-therapist”) there is going to be variety in delivering the
treatment modality (age, gender, physical conditioning, therapist-patient
interaction, therapist’s understanding of the modality, levels of training, etc.).
Averaging out the data by mathematical probability models by necessity will
ignore many of these variables and thereby make the results less relevant to
actual clinical outcomes. On the other hand, restricting the variable (only one
gender, age group, equal training and experience – if that is even considered a
reasonable possibility) would mean that the results calculated would only
apply to that restricted group of agents and, therefore, would be even less
relevant to actual clinical outcomes.
If only one agent/therapist is used (“intra-therapist”) in a study then,
strictly speaking, the results of that study apply only to that individual (or
their clones), resulting in even less relevance for the outcomes.
Mega-studies have their own issues. It must be remembered that the
studies collected and found acceptable are rarely “replications” in the true
sense. Without replication (as closely as is feasible) a research study cannot
claim reliability. “Similar” or “related” is not replication. But more often than
not mega-studies are just that: a collection of similar studies. Though each
individual research study used may have calculated its own specific
probability, without replication this probability for a specific result or
conclusion remains in question. Combining a number of questionable
conclusions does not somehow magically make that cumulative conclusion
less questionable. While mathematical models used to calculate the results of
such mega-studies may claim they impart reliability or validity to those
results, such reliability can only be granted to the mathematics and not the
content.
This is not an argument to discount evidence obtained from rigorous
research. I only criticize the idea held by some that double-blind studies are
the most acceptable evidence on which to base one’s practice, and on the
other hand, that evidence from clinical experience (both one’s own and
reports from others) is highly suspect. Both of these sources (research and
experience) need to be treated equally and in turn need to take into account
the client’s/patient’s social values and expectations (and consent) when
applying such evidence-based treatment in order to strive for the best
outcomes possible.

Outcome-based massage
My preference is for the term outcome-based massage. While evidence from
many sources is used by a therapist in developing the most viable, effective
and safe treatment plan for their patient, the outcome is made up from more
than just this. The outcome, as noted above, is also based on the patient’s
expectations (personal and social), understanding (being informed), the
therapeutic relationship (trust), and the consent granted. Treatment (which
includes assessment) is therefore always more than evidence-based.
Evidence-based practices are a necessary component for best practice in
massage therapy, but they alone do not shape the outcomes achieved in
clinical practice.
With respect to the research being done on manual assessment testing that
is aimed at building an evidence base, much of that information requires a
history of health care training or clinical experience in order to be of
relevance to, let alone to be understood and appreciated by, any student of a
health care profession. In light of the brevity of training that most massage
therapists receive (and I include in this the lack of any preparatory education
in the health sciences that the majority of massage therapy students possess
upon enrolling), the information meant to be conveyed by evidence-based
texts on manual testing may convey little to such a student body. In fact, it is
only after they have completed their training, passed competency
examinations, and acquired some clinical experience (beyond their public
clinic experience during schooling) that most practicing massage therapists
have the tools to explore and appreciate this information. Once a student has
learned a specific test, and used it a number of times with a variety of patients
(which often means after they have been practicing for some time), they can
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