by Stephen Ryason, LMT, MMT

As massage therapists, we occupy a unique place in the field of healthcare. Massage therapy when applied correctly has been proven to be highly effective and, in many cases, essential to the successful treatment and resolution of various musculoskeletal, neurological, visceral, psychological and emotional abnormalities.

Although the therapeutic tools we use are limited, they can be incredibly powerful when used correctly. Our “toolbox” contains many implements. We have the seven “basic” techniques of effleurage, friction, kneading, compression, percussion, vibration and stretching, each with numerous variants. We also have numerous “advanced” techniques that we may utilize also. Neuromuscular Therapy, Muscle Energy Techniques, Connective Tissue Massage, Trigger Point Therapy, Myofascial Release, Lymph Drainage Massage, and Periostal Massage are examples of these advanced techniques.

When our clients come to us with general/specific and/or acute/chronic complaints, it is our responsibility to determine which technique or techniques should be used, and in which combination, duration, order and frequency they should be applied for the maximum influence on the targeted abnormality. With all these tools at our disposal, how do we determine which techniques or combination of techniques to use?

Initially, we begin with the visual observation of the client’s gait, body language, facial expression, etc. This first visual assessment gives the practitioner some clues about the pathological abnormality he or she currently faces.

The next step is the client interview. An excellent source of this information is the article “Science of Clinical Interview” published in #1 Issue 2012 of JMS. Readers will find everything they need including a ready-to-print form to use for the client’s initial evaluation.

The clinical interview follows with a visual observation of the body at rest in a relaxed position and a visual observation of the area the client is complaining about. The final stage is the physical examination that includes palpation, detecting ROM, the application of various tests, etc.

Once we have gathered this initial information, we must use our intuitive and cognitive skills to formulate a treatment protocol. Most massage therapists have a well-developed intuitive ability. Intuition is a visceral/emotional, “non-thinking” process that we can and should use in determining the appropriate course of action. We open our minds and ourselves to the client to see what impressions or clues we receive, and we use these impressions to help guide our treatment choices.

Like anything else, intuitive ability can be further developed with training and practice. We have all met someone who possesses a well-developed intuitive ability, and seeing this in action can be truly awe inspiring.

While our intuitive abilities should be used in guiding our decision making, it would be a disservice to our clients and us to rely solely on them in our decision-making process, especially in the early stages of our practice. Thus, we should and must use our cognitive skills as well.

Just like intuition, cognitive skills also may be developed with training and practice. One of the most effective ways to accomplish this development is to use the process of Critical Thinking.

Critical Thinking skills may be applied to almost any situation. The skills may be tweaked or modified for specific instances, but the basic principles are universal.


So what is Critical Thinking? A quick Internet search will provide an impressive array of resources, explanations and definitions devoted to the subject. I will use one that I believe is appropriate for the discussion at hand.

Critical Thinking is:

“the process of actively and skillfully conceptualizing, applying, analyzing, synthesizing and evaluating information to reach an answer or conclusion.”

Whew! Sounds pretty complex, right? Another definition that is not so overwhelming would be:

“disciplined thinking that is clear, rational, open minded, and informed by evidence.”

In order to “do” Critical Thinking, we need a certain set of skills. We also need a process or procedure by which to apply these skills. There are many different skills that may be used when applying Critical Thinking to a particular problem, but the core skills needed in almost all situations are: observation, interpretation, analysis, inference, evaluation, explanation and metacognition (i.e., knowing about knowing).

We, as practitioners, may use these skills to accomplish several effective clinical tasks:

1. Recognize problems and find workable solutions to them 

You have worked your entire professional life to do that including obtaining degrees and certifications, taking continuing-education classes and investing time and effort in self-education.

2. Gather pertinent information 

This is your initial visual observation, clinical interview and physical examination of the client.

3. Prioritize and understand the order of preference in problem solving 

You gather all the information you can. Now, it is time to prioritize information that is relevant for you and your client

4. Interpret data, appraise evidence 

If you are not sure of the direction in which to go, you may find help in published sources or from Internet professional groups. However, you need to work with this information critically and use the parts that are relevant for the client

5. Comprehend and use language clearly, accurately, and with discernment 

Everything you find during evaluation plus what you discovered by reviewing other sources, must be explained to the client in understandable language using simple analogies to clearly deliver a diagnosis. You must have the client on your side as an active participant in the treatment process

6. Draw warranted conclusions and generalizations 

At this point you have secured your client’s participation in the treatment, and it is time to finalize the treatment protocol. Based on all the information you have gathered and analyzed, you are in a position to make some conclusions and predictions, e.g., how long the treatment will take, do you need the help of other health practitioners (e.g., chiropractor, steroid injections, etc.).

You are in the position to make some generalizations as well. Does the client face a one-time fix or does his or her condition require regular treatments to support achievable results (e.g., the nature of scoliosis as a pathological condition would require supportive therapy on a regular basis).

7. Test these conclusions and generalizations 

This is the final step in the process of your critical thinking because now it is time to test the protocol you developed on your client. If you do not observe any positive dynamics after the first two to three sessions, it is likely you have made a mistake in your evaluation and application of your critical thinking skills.

Critical Thinking is the foundation of a successful clinical protocol of medical massage therapy.


Another cognitive skill that we can develop that relies heavily on Critical Thinking is Clinical Reasoning. What is Clinical Reasoning? An Internet search yields an assortment of literature, information, explanations and definitions about Clinical Reasoning. Here are two definitions that I believe are most pertinent to our discussion:

“ways of thinking that therapists use to understand clients and their problems in doing routine occupations.”


“the cognitive process whereby conclusions can be reached on the basis of information available.”

Clinical Reasoning requires certain skills and a procedure to follow similar to Critical Thinking. Clinical Reasoning is the thinking that helps therapists understand the client’s problems and how to intervene successfully.

There are six aspects of Clinical Reasoning: description, observation, link to knowledge base, hypothesis, implementation and evaluation. I would like to illustrate each aspect of Clinical Reasoning using one of my clients as an example:

1. Description 

The aspect of description includes the client’s complaints. For example, in this particular case, my client’s complaints included: Pain in the lower back in the morning and when he gets up from sitting in a chair; tingling sensation on the top of the right foot; occasional numbness and a shooting, burning pain below the knee along the lateral aspect of the right leg and on the top of the foot. The intensity of the pain increased at the end of the day. He lives in a two-story house and recently he noticed that his right leg was getting tired very quickly especially when he climbed the stairs.

The client experienced the onset of acute pain four months ago and an initial epidural injection took the edge off the pain, but follow-up physical therapy and chiropractic care were not able to completely eliminate his symptoms, which were affecting his quality of life. He was diagnosed with Chronic Sciatica due to an acute spasm in the piriformis muscle.

2. Observation 

The observation aspect includes visual observation and observation of the results of various testing.

Visual observation

As soon as I saw the client, his body gave me the first important clue. As he walked, it was obvious that he showed positive Freiberg’s Sign, which is clinical evidence of the shortening of the piriformis muscle that rotates the foot outward while the client walks. I also observed the same result in the lateral rotation of the foot when the client was on his back. I will use a video illustration of Freiberg’s Sign from the Video Library of


Observation of the Tests

An application of the Sensory Test on the lateral side of both legs confirmed the presence of inflammation in the common peroneal nerve, which is part of the sciatic nerve. The test was positive since the client has less sensation on the affected side when I simultaneously stroked his skin using my index fingernails on both sides.

The Straight-Leg Raised Test was acutely positive on the right side. Examination of trigger point in the right piriformis muscle triggered a shooting pain down to the leg all way to the top of the foot.

Following my evaluation routine, I examined the origin of the innervation of the piriformis muscle that is at the level of L5-S1 vertebrae. An application of the vertical and lateral pressure on the spinous process of L5 did not trigger an acute pain reaction. However, as soon as I applied pressure along the medial surface of the right sacroiliac joint, the patient withdrew his body and reported acute radiating pain to the right gluteal area and all way to the lateral surface of the leg. This acute pain was a surprise to the patient since he did not feel it without me applying the Compression Test there. After the test, the client told me that this was the exact pain he had experienced four months ago when his physical problems began.

The evaluation of lumbar erectors and quadratus lumborum muscles showed overall increased tension while the client did not react to the presence of active trigger points there.

3. Link to Knowledge Base 

Since the client had already gone through various therapies in addition to my own clinical experience, I decided to consult various sources to make sure that my thinking was on the right track. I visited the Video Library and went over the evaluation protocol. I also consulted Medical Massage, Vol. 1, as well as various Internet sources.

4. Hypothesis 

Here is the hypothesis I developed for this patient. There is no doubt that he suffers from Chronic Sciatic Nerve Neuralgia and to be more precise he has Common Peroneal Nerve Neuralgia since the common peroneal nerve is part of the sciatic nerve. He also showed positive readings for for all tests for acute spasm in the right piriformis muscle. Besides the initial epidural injection, all treatment so far had targeted the piriformis muscle as the primary cause of his symptoms.

Since several therapists had already worked on the piriformis muscle without achieving stable clinical results, I assumed that there was another cause of his symptoms. My initial evaluation confirmed the presence of chronic spasm on the right lumbar erectors and presence of pressure on the L5 spinal nerve under the right SI joint. This fact allowed me to develop a logical chain of events that would explain my client’s symptoms.

At some point, his body had not been able to compensate for the gradually acquired tension in the lumbar erectors and he entered stage of decompensation which triggered an acute clinical picture of sciatica. At this time, the epidural injection had been implemented and had relieved the acute symptoms associated with Sciatic Nerve Neuralgia. However, the initial problem with the lumbar erectors was not addressed and active trigger points had been put in the sleeping or latent state with conservative therapies.

As a result of the erectors’ shortening, the right sacroiliac joint became slightly twisted and it mildly irritated the L5 spinal nerve located under the SI joint. One of the first outcomes of L5 irritation is acute spasms in the piriformis muscle that is innervated by L5. Such spasms will secondarily compress the common peroneal section of the sciatic nerve with sensory and motor abnormalities developed on the lateral leg and top of the foot.

This theory explains why the patient’s treatments, which were done in the right gluteal area to the target the piriformis muscle, did not produce stable clinical results. The tension in the piriformis muscle was consequence of chronic spasm in the lumbar erectors and SI joint dysfunction.

5. Implementation 

To check if my theory was correct, I saw that my primary goal was to implement a MEDICAL MASSAGE PROTOCOL to reduce the chronic tension in the lumbar erectors on the right side, realign the right SI joint and give the L5 spinal nerve enough room to function. I decided to address the tension in the piriformis muscle later after normalizing the function of lumbar erectors

6. Evaluation 

After the first three sessions of medical massage and restoration of the anatomical length of the lumbar erectors, the patient reported a loud click in the lower back while he conducted his home-stretching routine. He immediately felt considerable relief from his peripheral neurological symptoms and my evaluation confirmed that the right piriformis muscle exhibited a very mild almost residual tension.

It is my strong, personal belief that Clinical Reasoning is an irreplaceable tool that aids the therapist to treat difficult, chronic cases in which various somatic abnormalities have accumulated, complicating examination and treatment.

If you compare Critical Thinking and Clinical Reasoning it will be obvious that they overlap significantly. It can be said that you can “do” Critical Thinking without Clinical Reasoning, but it is impossible to “do” Clinical Reasoning without Critical Thinking Skills.

There is no doubt that these cognitive skills require knowledge and effort to learn and develop. Most therapists already unknowingly use aspects of both Critical Thinking and Clinical Reasoning in their interactions with their clients. By studying and learning these skills and, most important, by constantly using and practicing Critical Thinking/Clinical Reasoning, we will continue to expand and improve our knowledge and expertise to greater heights, and in conjunction with our intuitive abilities, we will become more accomplished and effective massage therapists.

Category: Medical Massage