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CONSENT/ TREATMENT PLAN STEMS
1
Your patient is a 40-year-old mail carrier. She started running 2 years ago and then started
mountain biking about a year ago. She is very involved in both activities, runs about 4 times a
week and rides about 3 times a week. She recently (3 months ago) ran her longest race, a halfmarathon (21 kilometers), at her fastest pace that she has completed that distance at. She felt
fine during the race, just generally tired due to the exertion. About 3 days later she started
noticing lateral knee pain when she went running after taking a few recovery days off running.
Now when she runs, she experiences sharp pain very localized to the superior posterior aspect of
her right lateral femoral condyle. This pain forces her to stop at a distance of 2 kilometers. This
has been happening since the race about 3 months ago. She has fascial restrictions in her right
hamstrings and iliotibial band, a trigger point in right gluteus medius and is developing adhesions
at the lateral femoral condyle.
She has no other contraindications to massage therapy. She has been taking advil as needed but
has not taken any today.
Please explain your initial and on-going treatment plan to your client and obtain consent for
treatment.
2.
Your patient is a 40 year-old woman. She has never had a massage before but her doctor
recommended she try massage therapy for the stiffness she is feeling in her back. She admits
that she has poor posture at work, as she is a hair stylist. The majority of her tightness is in her
low back, however on occasion she feels aching in her upper back and even some occasional
headaches.
She is 5 months pregnant and not sure if she will be able to lie on her stomach for the treatment.
She has no problems with her pregnancy and no other medical conditions requiring any
modifications to the massage treatment.
She is taking no medications and has no allergies to oil or lotion.
She would like the treatment to focus on her back but is open to having other areas treated upon
your recommendation
Please explain your treatment plan to your client and obtain consent for treatment.
3.
Your patient is a 40 year-old woman. She has never had a massage before but her doctor
recommended she try massage therapy for the stiffness she is feeling in her back. She feels a
nagging type of ache in her right thoracic area. She comments that her ribs feel “really
uncomfortable”, pointing to ribs 6, 7, 8.
Assessment results:
• Observation reveals a mild-moderate S curve scoliosis, with the thoracic curve being to
the right and the lumbar portion being to the left. Consequently her iliac crests/pelvis is
unbalanced and slightly rotated.
• Her right scapula is winged somewhat in comparison to the left.
• Fascial restrictions in her thoracic area, particularly on the right.
• Trigger points in quadratus lumorum, subscapularis and infraspinatus.
• Right upper trapezius is hypertonic and in a shortened position
She is requesting a treatment to focus on her back.
Please explain your treatment plan to your client and obtain consent for treatment.
4.
Your patient is an avid golfer. When golfing last week, she felt an odd “twinge” and “pulled”
sensation in her lower thoracic area on the right side. The area is only slightly tender to touch
now. It was quite bothersome for 2 or 3 days, making normal activities a little challenging. She
was able to do all of her normal work and recreational activities, just with a bit of discomfort.
The area she points to is around ribs 9, 10, and 11. She also comments that she has chronic
muscle tightness in her upper back.
Assessment results:
• Palpation reveals moderate tenderness on the left thoracic area instead of the right.
The “injured” area does not appear to be tender, however when performing various
movements, there is definite pulling still felt there on the right.
• Fascial restrictions on her right mid-thoracic area
• Trigger points bilaterally in her rhomboids
• Hypomobility of her ribs, particularly 9, 10 and 11, on the right side
• General hypertonicity of all upper back muscles
She is requesting a treatment to focus on her back. She has had numerous massages in the
past, some of which she felt too painful
Please explain your treatment plan to your client and obtain consent for treatment.
5.
Your patient is requesting a massage focusing on their back, ribs and abdomen. Your patient was
in a minor car accident about 6 weeks ago. No bones were fractured, however bruising was
evident and swelling lasted for about 2 weeks over the left ribs 7, 8 and 9 along the side and
wrapping around to the front. The ribs were quite tender to touch for about 2 weeks and certain
movements were painful. These movements include trunk rotation and trunk extension. Pain was
felt as a pulling or stretching of the tissue around these ribs. No tenderness or bruising remains,
however what does remain is a reduced amount of movement throughout the thorax, particularly
in lateral flexion to the right. They are hoping a series of massage treatments will help.
Assessment findings:
• trigger points in serratus anterior
• hypomibility of ribs 7, 8, 9 near the most lateral part of the ribs
• fascia restrictions and scar tissue between ribs 7, 8 and 9 near the most lateral part of
the ribs
Your patient also has asthma and takes ventolin as needed, which is pretty much on a daily
basis. They occasionally take advil for fairly frequent headaches, and took an advil this morning
at about 7am for a light headache that was just starting.
Explain your initial and ongoing treatment plan for your patient and obtain consent for
treatment. Ensure your patient has full understanding of everything you discuss.
6.
Your patient has never had a massage before and is quite nervous about the whole process.
They were recently diagnosed with rheumatoid arthritis after several months of sometimes
general and sometimes sharp pain mostly in their arms and legs. The worst area seems to be
arms, wrists and fingers. Being so young, the disease process is early and not terribly limiting.
They are currently experiencing back and shoulder pain from shoveling snow a few days ago.
They are hoping the se if massage will help that and then discuss the benefits of a long term plan
for massage therapy to help with the muscle and joint discomfort due to the rheumatoid arthritis.
They are currently taking a regular prescription of paxil (deoression) and celebrex (arthritis)
Assessment findings:
• rounded shoulder posture
• hypertonic pectoral muscles
• trigger point in quadratus lumborum
• fascial restrictions in the pectoral area
• general reduced ROM in the cervical spine in all directions
Explain your initial and ongoing treatment plan for your patient and obtain consent for
treatment. Ensure your patient has full understanding of everything you discuss.
7.
Your 25 year old patient complains of right hip, knee and foot pain related to a new program of
running. They just began running about 2 months ago and started taking pilates classes as a way
to manage and try to improve their fibromyalgia symptoms and their frequent constipation. The
muscle ache, fatigue and abdominal issues seem to be improving so they do not want to stop
running. They are willing to do whatever it takes to help. They will do exercises, stretches, area
are open to suggestions. They take regular vitamin D supplements, as well as a prescription for
cymbalta (fibromyalgia) and amitzia for constipation as needed.
Assessment findings:
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Tenderness at the lateral femoral condyle, lower iliotibial band, lateral sacrum and soleus
Trigger points right biceps femoris and psoas
Hip lateral rotation and extension are uncomfortable but not reduced on the right
Hypertonicity and shortening in gastrocnemius
Fascial restrictions in the iliotibial band, rectus femoris and calf muscles
Your patient is requesting a massage only on the right leg as they are concerned about
being in more pain because of the fibromyalgia Explain your initial and ongoing treatment
plan for your patient and obtain consent for treatment
8.
Your patient is a 40-year-old auto mechanic. He started running 2 years ago and then started
mountain biking about a year ago. He is very involved in both activities, runs about 4 times a
week and rides about 3 times a week. He recently (3 months ago) ran his longest race, a halfmarathon (21 kilometers), at his fastest pace that he has completed that distance at. He felt fine
during the race, just generally tired due to the exertion. About 3 days later he started noticing
lateral knee pain when he went running after taking a few recovery days off running. Now when
he runs, he experiences sharp pain very localized to the superior posterior aspect of his right
lateral femoral condyle. This pain forces him to stop at a distance of 2 kilometers. This has been
happening since the race about 3 months ago. He has fascial restrictions in his right hamstrings
and iliotibial band, a trigger point in right gluteus medius and is developing adhesions at the
lateral femoral condyle.
Please explain your initial and on-going treatment plan to your client and obtain consent for
treatment.
9.
Your patient is complaining of right elbow pain. Sharp pain is felt on palpation, localized to the
right medial epicondyle at the insertion of the common flexor tendon. Tenderness is located a bit
proximal and distal as well. Repetitive actions such as golfing and gardening increase the pain.
With these activities pain is very specifically felt at this spot. Medical testing has concluded this is
not medial epicondylitis, but is related to cervical compression sustained in a motor vehicle
accident 6 months earlier. X-rays show significant compression between the C5 and C6
vertebrae. Assessment reveals reduced forward cervical flexion and lateral flexion to the left.
Facial restrictions are present over the right lateral neck, pectoral area and into the right upper
arm. A trigger point is present in flexor carpi radialis.
Please explain your initial and on-going treatment plan to your client and obtain consent for
treatment.
10.
Your patient is a 62-year-old factory worker. He has been diagnosed by his physiotherapist with a
partial supraspinatus tear and moderate bicipital tendonitis of the right shoulder. Both of these
are in a chronic stage. He has had right anterior shoulder discomfort for over 6 months. There is
no swelling or heat present. He has sharp pain on palpation of his right biceps tendon near its
proximal attachment, where adhesions are forming. He also explains that both arms “fall asleep”
every night, with numbness down the arm and into the medial 1 ½ digits. Palpation also reveals a
trigger point in right pectoralis minor. His cervical rotation is reduced by about 50%, with rotation
to the left being worse than rotation to the right. He has a great deal of hypertonicity in his right
upper trapezius and scalene muscles also. He is receiving physiotherapy treatments twice a
week. This will be his first massage ever.
Please explain your initial and on-going treatment plan to your client and obtain consent for
treatment.
11.
Your patient is an 18-year-old competitive hockey player. He fractured his right fibula at the lateral
malleolus a year ago. The bone healed well, however he started back to skateboarding a bit too
soon and continues to experience swelling and restriction in the soft tissue and ankle joint.
Recent x-rays reveal perfect bone healing. His right ankle exhibits a moderate amount of chronic
swelling and tissue thickening. His dorsi flexion is limited by about 30%. The limitation is painless,
as he continues to play hockey and skateboard but the limitation is preventing the full movement
that he feels is necessary. He has fascial restrictions in his posterior compartment of his leg and
he has a trigger point in tibialis anterior. He received numerous physiotherapy treatments for the
first 6 months after the fracture but is not doing any type of therapy now.
Please explain your initial and on-going treatment plan to your client and obtain consent for
treatment.
12.
Your patient is a 55-year-old woman. She has massage treatments about once a month; the
focus is usually her gluteal area, and her back. At this visit she mentions that her knee is very
swollen, stating that it started about 3 weeks ago and she just woke up with it like that one day.
Observation reveals her right knee is about double the “normal” size. She has seen her doctor
and he says it is probably arthritis beginning and this is a flare-up. Due to the discomfort though,
she has been adjusting her posture to compensate. Assessment reveals a hypomobile right
sacroiliac joint and posteriorly rotated pelvis particularly on the right side. She also has a
shortened psoas on the right from pulling her leg up off the ground into hip flexion. She also has
fascial restrictions in her right gluteal and hamstring muscles.
Please explain your initial and on-going treatment plan to your client and obtain consent for
treatment.
13.
Your patient was in a very bad car accident 20 years ago, when she was 18 years old. She
fractured 4 vertebrae and 4 ribs. Surgery and physiotherapy helped everything heal very well so
that she regained full strength and mobility. She began running a few years ago and has recently
increased her mileage. She is now feeling discomfort in locations where she has not felt pain in
years, the areas that were injured in her accident. She is also getting a few tension headaches a
week. Observation reveals a mild-moderate degree of thoracic kyphosis due to the fusion of
several vertebrae (T5-T9). She has a trigger point in her right lower trapezius, and hypomobilty of
her upper thoracic ribs, ribs 2-4. She has shortening and fascial restrictions in her pectoralis
major muscles bilaterally. Her posterior cervical muscles are also hypertonic.
Please explain your initial and on-going treatment plan to your client and obtain consent for
treatment.
14
Your patient is a 35-year-old dentist. He has never had a massage before but a friend
recommended he try a massage. He has been complaining of shoulder, neck and arm pain and
fatigue, likely due to his posture at work. He spends much of his day leaning over patients
working on their teeth. His right side bothers him a little more than his left side. He is unsure of
what to expect from the treatment and not sure if it will help. He is wondering if you will be able to
help restore full movement in his neck and shoulders.
He has no medical conditions requiring any modifications to the treatment.
He is taking no medications and has no allergies to oil or lotion
Please explain your treatment plan to your client and obtain consent for treatment.
15.
Your patient is a 30-year-old competitive hockey player. He has just started practicing, preparing
for the upcoming hockey season. His legs are generally achy and tired. He says this happens at
the start of every season and finds if he starts having regular massage therapy, then his legs
never get too sore. He would like most of the treatment time spent on his legs, anterior and
posterior, however is open to suggestions of any other areas you think may be of benefit to treat.
He is interested in coming for treatments on a regular basis.
He has no contraindications to massage therapy and is not taking any medication and has no
allergies to oil or lotion.
Please explain your treatment plan to your client and obtain consent for treatment.
16.
Your patient is complaining of right arm and shoulder tightness. Repetitive actions such as golfing
and gardening seem to have caused the pain and tightness. The pain is mild-moderate, and the
patient reports it just feels like the muscles are tight from working them too hard. Her doctor
recommended massage therapy, stating that there is no reason to avoid pressure on the area.
She is not taking any medication and has no other medical conditions and has no allergies to oil
or lotion
She would like to feel a reduction in the tightness in her shoulder and upper back area and would
like a treatment focused on this area
Please explain your treatment plan to your client and obtain consent for treatment.