Acknowledgements and Disclaimers

Many thanks to past teachers, assistants, colleagues, and participants for their assistance in the development of this work and this manual. Teachers who have influenced these materials include Neal Powers, Emmett Hutchins, Liz Gaggini, Til Luchau, Nilce Silvera, Andy Goodwin, Michael Salveson, Art Riggs, and Jan Sultan, to name a few. Of course, also to be mentioned is the groundbreaking pioneer in this field, Dr. Ida P. Rolf, without whom, none of this would have been possible.

Special thanks to Linda White and Billie Shea, great teachers and practitioners here in Nevada, striving to better both the field of bodywork and the practitioners within it. And of course, many thanks to Eric Asay, the photographer and web site designer making this presentation possible.

Disclaimer: This course teaches soft-tissue mechanics and positioning for students and practitioners of manual therapy/massage therapy/bodywork. This is not a course in Rolf Structural Integration.

These methods do not constitute medical treatment and a physician should be consulted in advance about any conditions that are questionable or might contraindicate this work. While every attempt is made to insure the safety of the techniques taught, participants assume all risk for participation and subsequent application of the techniques learned.

It is recommended that students review anatomy before the class begins and use anatomical charts or books to aid in the understanding of this material.

Preface

Often overlooked and always undervalued, mechanics and positioning are what typically separate a short career from a long one, create a dynamic and creative practice, and produce substantially better results for the client.

Mechanics hits home on two fronts – without good mechanics a practitioner is prone to injury and possible the cessation of the career. Good mechanics is also a huge component of “touch”. The difference between and poor mechanics is quickly obvious to the client from what they feel, and what they feel, when it comes to building your business, is often a bigger factor than how much knowledge or experience you have.

With mechanics, the number one goal is to work easier and more relaxed and that feeling of ease and relaxation is what you want to convey to your clients. An easy touch, a relaxed touch, and a listening touch are what you strive for and why clients will prefer you to other practitioners.

Positioning in our profession is often all too predictable – 40 minutes in prone and 20 minutes in supine and you’re done. Unfortunately, this is exactly what client’s have become used to and this has proceeded from a commonality to an expectation. Practitioners, knowing this expectation, find it all too easy to comply with this tradition, regardless of how beneficial it may or may not be. To be clear, even when you are doing purely relaxation massage, there are positioning options available to you that will enhance the massage and even the relaxation of the client. In a more clinical setting, if you are only primarily utilizing only a prone position, you are more than likely doing a disservice to your client. When treating a disorder, positioning can make all the difference between an effective and an ineffective technique, client comfort, and practitioner comfort. Further, positioning and how you utilize it can make you a very distinct practitioner in an ever-growing field. If you wish to stand out from the rest, positioning is one way in which to do it.

I. Setup Considerations

A. Draping – underwear vs. bare

Having the client in underwear allows for easier positioning and draping. At times, less draping will be necessary making underwear essential. Underwear also gives the client a greater sense of safety. Clients are often “used” to being naked and often expect this, however, in a clinical setting where you may need the client to be in multiple positions; underwear makes the whole time-consuming issue of draping one that is less pressing and certainly less stressful.

The rules of draping where drafted with overtones of prostitution and sexual assault in mind. However, when it comes to working with a client in a clinical sense to resolve a particular musculo-skeletal issue, these archaic rules do nothing but inhibit us as practitioners. To work more effectively, one must be able to “see”, whether that be while working with a client during a session, or before the session even begins, assessing where tissue is held or shortened.

B. Table Height

Clinical and deeper work often requires the table height to be lower than for other modalities, such as Swedish. The table height should be such that the practitioner can bring his/her weight to bear with arms in a fairly straight position. Also of use here is a small stool from which the practitioner can stand in order to bring more weight to bear. The important thing here is to be able to work comfortably, and if you cannot use your weight to do the work and are instead relying on muscle power, you are straining yourself.

C. Lubrication

For deep work, clinical work, and myofascial release, less rather than more lubrication is necessary. You can’t use your weight if you are sliding off of your clients. The key here is to engage tissue, not slide over it. Less lubrication allows for slower work, allowing you to feel what is happening.

For clinical work, it is recommended that you use a lotion rather than oil. Often, you may only want to use a small amount of over the counter skin moisturizer – enough to ensure that the client will be comfortable as you engage the tissue, but not too much that you unintentionally slide. Over-lubrication actually makes it harder to work and causes you to strain.

D. Speed

Most deep, clinical, or myofascial work should be done at a much slower pace. This allows tissue to respond and minimizes any bruising. Go in slow, work slow, and come out slow. For lighter or more vigorous massage such as a pre-event sports massage, speed may be required, but most of the time, slowing down is both beneficial for us as practitioners, and for our clients who feel a more relaxed, easy, sensitive touch.

E. Straight arms vs. bent arms.

While this is often just a question of mechanics, the reason it is being mentioned here is because your setup (table height, stool height) will often dictate whether you can use pressure with straight arms. Bent arms require muscle effort. Straight arms put the burden on the skeleton and allow the practitioner to fully utilize his/her weight while working. Another consideration here is whether you will need to raise (shrug) your shoulders in order to straighten your arms while working. Table and stool height should be adequate (or you should have something elevated to stand on) for your arms to be straight and your shoulders relaxed while exerting downward pressure.

F. Unilateral vs. Bilateral work.

Your approach to a session is extremely important. I preach to all students and practitioners that it is very important to work both sides of the body. Deep/Myofascial work can and will change structure. Unless you well schooled in biomechanics and are certain of which tissue structures need unilateral/asymmetrical attention, always work both sides of the body -- this will insure the safety of the client.

“Both sides” of the body also means more than just working the right side and the left side, it also means front and back. Most clients receive too much back work as opposed to opening work on the front and sides of the body, where most flexion takes place.

As a general rule, the energy added by massage, especially deep massage, causes tissue to lengthen. Shortening (adding tone) to tissue is much more difficult and arguably impossible. The lesson here is if you are going to work the back, which is often over-lengthened to begin with, you best address the front of the body as well.

II. Mechanics

A. Body Position

The first rule is to be comfortable.

Legs should be relaxed, often flexed at the knees, one leg in front of the other, front leg more flexed than the back leg. For foot position, it is often better to lead with the foot on the same side as the working hand. The opposite will cause you to try to work across your body, twisting and putting the shoulders in an uncomfortable position.

Whether you are working seated or standing, it is highly important to stay relaxed in the shoulders and lower back. For shoulders, keep them down, staying long through your own trapezius and into your neck. Hunching your shoulders will quickly fatigue them.

For the low back, avoid breaking at the waist unless you are supporting yourself both with the lead leg/foot and with your arms or elbows. Avoid over-reaching as you will lose the ability to support yourself with your arms and the strain will transfer to the low back.

B. Elbows

All aspects of the elbow can be utilized from ulnar edge to the point (olecranon process).

The key here is to keep the hand and arm relaxed while working. It is best to be “limp wristed” in the working arm, allowing the forearm to completely relax.

The other, non-working hand may be used to feel the tissue being worked and guide the elbow. This is especially useful around the spine, where the free hand can feel for spinous processes while the elbow works in the spinal groove.

In using the elbow, the practitioners weight is being utilized...rather than “muscling” the movement. Slow work here is paramount. Allow for the tissue to respond and “melt” before moving directionally or deeper.

C. Fists

Fists can be very versatile tools. Key here is to keep the fingers relaxed and try to utilize a “thumb forward” position (especially in a “pushing” type motion). This reduces the number of points of weakness in the practitioner’s arms and wrists. With a pure downward stroke, the wrist should be in a more neutral position using a broad contact. Again, the fingers should be relaxed.

D. Knuckles

Knuckles are small tools that can be used instead of thumbs or fingers. Key here when using a “pushing motion” is to keep the thumb pointed down or backwards towards the practitioner while medially rotating the arm (elbow upwards).

As with fists, in a pure downward stroke, the wrist will be in a more neutral position.

E. Thumbs

Yes, it is OK to use your thumbs. It is not ok to overuse your thumbs but they are a tool in your toolbox. Supporting a thumb with another thumb or fingers from the other hand is highly recommended. Practitioner’s who have thumbs that hyper-extend should be more wary about using them but shouldn’t avoid them. Instead use extra caution not to hyper-extend or overuse the thumb. Also, the closer the thumb remains to the other fingers (and hand), the less stress on the joints. Extending your thumb fully in order to work adds much more stress to the joints.

E. Hands and Fingers

Typically should be used more for pushing rather than pulling or grasping. A slight curve or arch is key here – that is the position of strength. Wrist bend should not approach a right angle (90 degrees). The less bend in the wrist, the better. Those with smaller hands must be more attentive to form.

F. Palms/Heel of the Hand

Great tools for both working and assessing tissue. As with hands and fingers, the key is to keep the wrist at a comfortable angle. Over-extending on the wrist will both stress the carpals and the muscles of the forearm.

III. Positioning

A. Prone position

1. Limitations

Prone position is the most common of massage positions and is typically overused. Before we get into adaptations on prone, it is a good idea to see just why this position may not be beneficial for your client.

a. Lumbar and cervical compression. It can be very uncomfortable for many clients to lie in the prone position for an extended period of time, especially if they have lumbar problems to begin with or excessive lordosis. In the prone position, most lumbar and cervical work should be avoided, especially deep work on the lumbars. Both the lumbars and cervicals in prone are essentially “compressed” or shortened. Please understand that this is significantly different than a muscle being “on the slack”. Here, the spine itself is put into a vulnerable, compressed and restricted position.

When you put someone in a face cradle, take a look at the neck – do you see wrinkles in the back of the neck? If so, it is likely the cervicals are being over-extended. The solution is to either angle the cradle downwards in order to extend the cervicals, or, avoid doing any significant work on the neck in this position.

With the lumbars – ask yourself if the client looks comfortable. Also, determine whether they had an excess of lordosis (low back curvature) before the session. If so, being in prone for an extended period of time may be highly uncomfortable. Finally, ask your clients if they are comfortable in prone. Many just expect to be in prone for most of the session and don’t realize that they have the option not to!

b. The “suspect position” of the arm and “figure four” position of leg is often highly uncomfortable to clients. The “suspect position” is the type of position a prison guard would put you in to make you scream. Do you really want to do that to your client? This position is even more ridiculous if your client has a shoulder issue!

The “figure four” position is reminiscent of what a wrestler would do to you to make you tap out. This position often painfully shortens the deep hip rotators, compresses the hip (to a bone on bone feeling), and strains both the sacrum above and the adductors below. If you’re going to use this position, check and see if your client is a masochist.

2. Variations on Prone

Ok, now that we’ve bad-mouthed prone, lets take a look at what we can do with the position to make it both more varied and more comfortable.

a. Bolstering

Using pillows or bolsters under the lower leg and ankle will slacken the hamstrings and gastrocs. By virtue that the hamstrings attach at the pelvis, this will take some stress off of the lumbars and sacrum in the prone position. Slackening the hamstrings will also allow you to work the hamstrings with less effort to yourself and less pain to the client. Bolstering here will also allow for some dorsiflexion of the feet which will help prevent the feet from cramping.

Adding a pillow or two under pelvis and low abdominal area will take some of the compression out of the lumbars, thus creating greater comfort to the lumbar and sacral areas. Depending on your client, with bolstering here, it may be possible to perform deeper work on lumbars.

Many clients, when given the option, would rather not be stuck in a cradle. Instead these clients will simply turn their heads to the side. Make sure that client’s are remembering to switch sides every 5 minutes or so in order to reduce neck strain. If neck range of motion is limited, place a pillow under the shoulder on the side the head is turned in order to decrease the strain in the neck. This type of bolstering simply gives the head and neck more room and decreases the amount the client needs to turn their head.

b. Arm hanging. For shoulder issues, clients may need to move their arms and shoulders periodically. One position of comfort for the affected side is to have the client move towards one side of the table and allow one are to hang off, typically at the elbow. This allows for arm movement while working in the rotator cuff.

c. Head hanging. A great way to access the upper thoracics, rhomboids, traps, erectors, etc. Have your client, from prone, scoot headwards on the table and hang their head off of front of the table. This allows access to traps, upper erectors and T1-C7 area. Be careful here to make sure your client’s throat and breathing is not restricted by the table – ie: make sure the head is hanging far enough off of the table. Secondly, in this position, blood will go to the client’s head, hence, do not leave the client in this position for longer than a minute or two and stay in constant communication with the client.

d. Prone “C” position. Having the client sidebent while in prone position will open challenge the facet joints of the spine, making some spine work more effective. It is preferable here to not use a face cradle, instead having the client turn their heads to the same side as they are bending.

B. Sidelying Position

Sidelying is typically the most comfortable position for a client to be in. This position also offers multiple variations and allows for access to body areas that no other position can match.

1. Indications

a. This is the least vulnerable position for the client and often the most comfortable. The sidelying position is highly indicated for a client experiencing any type of low back discomfort

b. Sidelying is a good position to place client in should they experience any type of emotional release – it is the fetal position. This can also be a very safe way to start a session as well dependent on client’s initial emotional state. Typically, if a client experiences an emotional release, placing the client in sidelying will immediately allow them to feel safer, more secure.

2. Body Access

Sidelying allows for easy access to the hips (gluteals, TFL), as well as QL, trapezius, cervicals, peroneals, deep hip rotators, adductors and erectors.

a. Erector work in lumbars. The lumbars in sidelying are fairly extended and relaxed, making the sidelying position a better option to work in the erectors rather than prone. Having your clients curve to even more of a fetal position will decompress the lumbars further and open up the facet joints of the spine.

In working the lumbars:

1) Erector work with fingers, thumbs, knuckles – often easier to work on the lower erectors/spinal groove (closer to the table).

2) The “Window washer” technique with elbow/forearm.

3) Having client twist – helps open up erectors, lumbars. Here, like in the prone “C” position above, we are challenging the facet joints of the spine to open and we are working the spine into a greater range of motion.

4) Active movements - You can also have the client perform active movements such as curling (into more of a fetal position) as you work.

b. Adductors. Working the adductors in sidelying is the least vulnerable position for the client. Bring top leg forward (bend knee) and place pillow/bolster underneath the knee. Straighten bottom leg for easy access to adductors and inside of lower leg. The client’s genitals are now protected by their top leg while you have perfect access to the adductors all the way to the pubic bone.

c. Trapezius. In Sidelying, you can access trapezius all the way from the broad attachments near the shoulder all the way up to the base of the occiput. It helps here to work without a pillow as this lets the client drop their heads towards the table, putting trapezius on the stretch.

d. Deltoids. This is often a hard area to work in either prone or supine. However, in sidelying, the belly of the muscle is accessible and the practitioner can bring her weight to bear while working.

e. Axillary region. Sidelying is the best way to access the axillary region (armpit) along with the fascia on the rib cage as well as trapezius, teres major, serratus anterior, and the lateral border of the pectorals. Experiment with arm position here – the arm can be extended overhead to put the axillary region on the stretch. (with the arm extended over head).

C. Seated Position

Rarely used by most massage therapist because of draping issues. If draping is an issue, you can save seated work for the end of the session and ask your client to partially dress. When using a seated position, make sure that seat you use is stable (non-rolling) and allows for the client’s knee’s to be at the same level or lower than their hips and their feet to be out in front of them. The client, while seated, should be feeling their “sits bones” (ischial tuberosities) on the chair. Knees should be close together, feet on the floor and able to push back against you.

a. Traps, Levator Scapula. Easy access here and very useful for a client with upper back issues. Practitioners can use their elbow and forearm here. Active movement include having the client turn their heads while you work, or perform flexion and extension in the neck.

b. Lumbars/Lumbar fascia. With the client curled over (very comfortable if curled over a pillow), the practitioner can access lumbars with elbows and loose fists.

c. Erectors. As with above, the seated position allows for easy access to the erectors. You can work with the client’s back straight or curved forward.

D. Supine Position

While quad, abdominal, and hip flexor work here is a given, supine also allows for great access to other body regions.

a. Axillary region. With the arm open and bent there is easy access to the axillary region. This includes coracobrachialis, teres major, subscapularis, pec minor, axillary fascia.

b. Trap work. Here you can work with a loose fist pressing down into traps.

c. Rotator cuff work with arm adducted over chest. This puts infraspinatus and teres minor on the stretch and allows you to both access part of the muscles, the musculo-tendonous junctures, and the tendons of both.

d. Hamstring work. With the hip and knee flexed and one hand holding the clients leg, the practitioner can use a loose fist in a downward motion on the hamstrings, working the tissue from the back of the knee all the way to the ischial tuberosities.

e. Triceps. Triceps are easily accessible with arm extended over head or arm slightly bent and supported by either a pillow or the practitioners leg/knee.

f. Neck. Supine is the best way to work on the neck. Period. It allows for unlimited variations on sidebending, rotating, flexion and extension.

E. Working under the body

Working under the body is often incredibly useful to both feel and assess tissue restrictions and work with client’s who are bedridden.

When working under the body, you will be using your fingers (palms up). Keep the fingers bent in slight arch. Try to keep the arms and hands relaxed and lever with the forearm whenever possible. Working this way does require more hand strength, but as you utilize this method, your hands will grow stronger.

1. Supine position – Under the body

a. Very useful for working on elderly or bedridden clients who cannot be positioned otherwise. Allows the spine to be in a more natural and relaxed position (especially with knees up).

b. Neck

c. Rhomboid area

d. Erectors

2. Prone position. While not a typically advantageous, for variations and creativity you can work under the body in prone.

a. Hip Flexors, Quads

b. Pectorals

F. Other creative positioning

a. Child’s pose. This is a Yoga pose excellent for flexing lumbars and/or extending thoracics. Your yogi clients will appreciate this!

Child’s pose is just one example of using a yoga pose while you work. With many clients who practice yoga, you can target poses that they have trouble with. For example, have the client try the pose that is difficult for them (or one which they want to go deeper into). Assess where you think the restrictions are happening and ask the client where they feel restricted. You can now work those tissue restrictions while the client is in the pose, or you put the client back on the table to work the restricted tissue.

b. Standing work. Probably the least used positioning is standing. This position is usually only useful for working on the calves and ankles. However, as noted above, you can work with a client in a standing yoga posture.

Have fun and be creative!