Client Assessment and Planning Flashcards

A client reports, "I have a constant, dull ache in my right shoulder that becomes a sharp pain when I try to lift my arm overhead." In which section of a SOAP note would the therapist document this statement?

Answer: Subjective

The "Subjective" section contains information reported by the client, including their description of symptoms, pain levels, and how the condition affects them. This statement is the client's direct report.

A massage therapist performs a visual assessment and observes that the client has a significant anterior pelvic tilt and hyperlordosis of the lumbar spine. This pattern, often associated with tight hip flexors and weak abdominal muscles, is commonly known as:

Answer: Lower Crossed Syndrome

Lower Crossed Syndrome, a concept developed by Dr. Vladimir Janda, describes a postural imbalance characterized by tightness in the thoracolumbar extensors and hip flexors, and weakness in the deep abdominal muscles and gluteus maximus/medius, leading to an anterior pelvic tilt and increased lumbar lordosis.

While performing a passive range of motion assessment on a client's knee, the therapist is unable to achieve full flexion because the client reports severe pain. The therapist feels no tissue resistance before the client requests to stop the movement. What is this type of end-feel called?

Answer: Empty

An "empty" end-feel is characterized by the client stopping the movement due to significant pain before the therapist can feel any structural resistance at the normal end of range. It often indicates a serious pathology like a fracture, bursitis, or tumor.

A new client seeks massage for chronic neck stiffness and frequent tension headaches. When collaborating on a treatment plan, which of the following represents the MOST effective and well-defined initial goal?

Answer: To reduce the reported frequency of tension headaches from 3-4 times per week to 1-2 times per week over the next 6 sessions.

This is the best goal because it is specific (reduce headache frequency), measurable (from 3-4 to 1-2 times/week), achievable, relevant to the client's complaint, and time-bound (over 6 sessions). This follows the SMART goal framework, which is essential for effective treatment planning.

A client's intake form lists that they are taking Warfarin (Coumadin), a prescribed anticoagulant. This information indicates a specific precaution for which of the following massage techniques?

Answer: Deep friction and aggressive myofascial release

Anticoagulants (blood thinners) like Warfarin increase the time it takes for blood to clot, making the client more susceptible to bruising and internal bleeding. Techniques involving significant pressure, such as deep friction and aggressive myofascial release, should be avoided or modified to prevent tissue damage and hematomas.

During the initial client interview, which of the following questions is the best example of an open-ended question to assess the nature of a client's pain?

Answer: Can you describe what the pain feels like?

An open-ended question is designed to encourage a full, meaningful answer using the subject's own knowledge and feelings. "Can you describe what the pain feels like?" prompts the client to provide a detailed description, unlike the other options which are closed-ended and can be answered with a simple "yes," "no," or a single word.