Work Smarter,

not harder

by Joseph E. Muscolino, DC photos by yanik chauvin

body mechanics for massage therapists

Course Objective:

The efficiency with which massage

therapists use body mechanics in
the delivery of massage therapy is
crucial both to the quality of the therapeutic care and the longevity of our
massage therapy careers. Unfortunately, the study of body mechanics
is often given insufficient attention
and therapists work harder rather
than smarter, sometimes resulting in
career-ending injuries.
This course offers a set of 10
guidelines designed to create healthy
body mechanics when delivering massage and bodywork. These guidelines
show how to maximize the efficiency
with which we work by showing how
to harness the laws of physics, rather
than working against them.

This course is divided into three categories and offers 10 guidelines on how
to use equipment and supplies, how to position your body and how to perform
massage therapy strokes in a manner that maximizes efficient delivery and
minimizes stress on your body. While useful for all massage therapists, these
techniques are essential when performing deep tissue work. When you finish
this course you will be able to:
Q Define the role of body mechanics in massage therapy.
Q Describe how the delivery of force in massage therapy is affected by gravity,
table height and lubricant.
Q Compare the advantages and disadvantages of the stoop bend and the
squat bend in massage therapy.
Q Describe how foot positions and trunk orientation of the massage therapist
affect the strength of delivery in massage therapy.
Q Describe how delivery in massage therapy is affected by both head-andneck and upper extremity joint alignment.
Q Describe how the therapists use of larger muscles and a larger contact
area improves the delivery of massage therapy.
Contact Hours: 2.0

NOTE: Massage therapists are advised to practice these techniques prior to utilizing them in a clinical setting.

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Course Description:

bodywork,
body mechanics & physics

7.8

 mtj/massage therapy journal winter 2006

The average number of

years massage therapists
stay in the profession.1

Body Mechanics and Physics

Regardless of the technique employed, the essence of all forms of
physical bodywork is the delivery
of pressurein other words force
into the tissues of our clients. The efficiency with which we achieve this
is crucial, not only to the quality of
therapeutic care that we give our clients, but also to our own health and
longevity in the field. To examine
the efficiency with which our body
works, we must study the mechanics of our body; therefore this field is
called body mechanics.
Understanding and applying the
fundamentals of good body mechanics is simple. We need to apply the
laws of physics to our body. The
same laws of physics that rule all
physical matter including the moon
and stars governs the forces that our
body generates and to which our
body is subjected. If we work with
these laws of physics, we can generate greater forces with less fatigue,
effortlessly working on our clients,
and have our body subjected to less
force. But if we work against them,
it will be more fatiguing to generate
the power necessary to do our work
and our body will be subjected to
greater forces that may injure us.
When Working Hard = Injuries
Unfortunately, the study of body mechanics is often given insufficient attention in the world of massage and
bodywork. As a result, many new
graduates and established therapists

alike are often ill-equipped to do

deep tissue work without muscling
the massage via excessive effort. Instead of working smarter, they work
harder, resulting in a high number of
injuries. Many of these injuries force
otherwise able and successful therapists to prematurely leave the field.
On average, a massage therapist
stays in the field for only 7.8 years.1
While not all individuals leave as
a result of injury, certainly a good
number of them leave because of
injury, or due to the burnout that
occurs from the physicality of doing
massage. Giving massage and engaging tissue can be hard work, especially when done with poor technique!
Guidelines to Harnessing
Physics and Body Mechanics
The goal of this course is to offer a
set of 10 guidelines designed to create healthy body mechanics when
delivering massage and bodywork.
These guidelines do not constitute
a new technique or method; rather
they simply show how to maximize
the efficiency with which we work
by showing how to have the laws
of physics work with us instead of
against us.
These guidelines are divided into
three categories:
Q Equipment
and suppliesthe
massage table and lubricants;
Q Positioning of our bodieshow we
bend, the alignment of our trunk,
head, feet and joints;
Q Performing the massage stroke

To take the exam and earn your CE contact hours for this course, go to www.amtaonlinetraining.org. You can also download a
PDF of this course as it appears in mtj by going to www.amtamassage.org.mtj and clicking on the Earn CE Contact Hours link.

the origin of our strength, the

direction in which we apply the
stroke, and how we support our
contact with the client.
Using good body mechanics is important all the time; however, it is
crucial when performing deep tissue work, which requires a greater
production and delivery of pressure.
For this reason, these guidelines are
especially recommended to bodyworkers who do deep tissue work on
a regular basis. While this course is
not meant to be comprehensive of all
aspects and facets of body mechanics for bodyworkers, it does provide
a number of essential basics.
As much as following rules and
guidelines is important, it should
be kept in mind that bodywork is
not only a science, it is also an art.
Therefore, the following guidelines
need to be incorporated into your
own unique style.2

1a

equipment &
body mechanics
Guideline No. 1: Table Height
Table height is probably the number
one factor determining the efficiency of the therapists force delivery.
The exact proper height of the table
is determined by a combination of a
number of factors, including:
Height of the therapist;
Size of the client;
Positioning of the client on the
table (supine, prone, or side lying);
Technique being employed.

Body Weight and Gravity

Setting the table low allows the
therapist to take advantage of body
weight to create force.2 Weight is

1c

Figure 1 illustrates a therapist working on a client with the table set at three different heights.
In each photo, the blue arrow represents the force through the therapists upper extremity
into the client, and the green vertical arrow represents the component of force that is due to
gravity. Note that the vertical component vector is least when the table is set high (1a), and
is greatest when the table is set low (1c). Ideally, if the line of force of the therapist is almost
purely vertical as in 1c, nearly all the force can be delivered via gravity and little effort needs
to be expended by the musculature of the therapist. A good guideline to determine proper
table height for deep tissue work is to have the top of your table be no higher than the top
of the patella (knee joint).

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When it comes to the production

and delivery of force with less effort,
the table needs to be low.3

1b

2b

2a

 mtj/massage therapy journal winter 2006

Figure 2 demonstrates an easy method

using an ordinary bathroom weight scale
to determine how much effort is necessary
at different heights to generate force into a
clients body. By placing the scale lower and
simply leaning into it, the greatest pressure
with least effort is obtained.

merely a measure of the force that

gravity exerts upon mass;4 and because gravity is an external force
that never tires, why not take advantage of it?
When a therapist generates force
to work on a client, that force can
be created in two waysinternally
within the body by muscles, or externally from gravity. The internal
creation of force by musculature
requires effort on our part, and can
be fatiguing. However, the creation
of force by gravity requires no effort.
If the goal is to create force with the
minimum effort possible, it is desirable to utilize gravity as much as
possible.2
However, gravity does not work
horizontally or diagonally; it only
works vertically downward. Therefore, it only works if the therapists
body weight is literally above the
client. This requires the client to be
placed below the therapist; hence
the necessity of low table height.5
With the client located below the
therapist, the therapist does not
need to expend much effort; rather
it is only necessary to lean into the
client letting the therapists body
weight generate forceful deep pressure (Figure 1).2,6 Given that the
greatest weight of the body is located in the core (i.e., the trunk) of
the body, it is the trunk that must
be positioned above the client when
the therapist leans in.

you can effortlessly generate by passively leaning into the scale. Try to
create the same reading on the scale
through muscular effort when the
scale is located on a higher surface.
The difference in effort required is
the difference in work that the therapist must do. Multiply this by how
many minutes or hours the therapist
works per week/month/year, and the
cumulative effect of a table set too
high can be appreciated.

Prove it to Yourself
To test the principle of table height
at home, place a bathroom weight
scale on a chair or massage table
at various heights. At each height,
simply lean into the scale and read
the force that you are generating on
the scale (Figure 2). If the scale is
low enough so that you are directly
above it, note how much pressure

Electric Lift Table

When working with a table set lower,
there is another factor to consider.
A low table height is ideal when
deep pressure is desired; however, a
higher table height is actually easier
to work with when light pressure
is being applied. It requires less effort for lighter pressure if you stand
straighter and apply pressure to the

The Importance of Self-Support

When generating deep pressure by
leaning into the client, it is important for the therapist to maintain a
position of self-support; otherwise
the therapists control and balance
might be lost, decreasing the effectiveness of the session as well as the
clients comfort.2,7 This self-support
can be maintained via a strong and
stable stance of the lower extremities (this will be discussed more
fully in Guideline No. 5).
Table Width
It addition to the height of the table,
the table width must also be considered. The wider the table, the more
difficult it is for you to position your
body weight over the client; if the
client is located at the center of the
table, the client is farther away from
you. For this reason, a narrow table
is more desirable when it comes to
utilizing your body weight.7

client with strokes that are more

horizontally oriented. If the table is
set low in this scenario, you either
must bend to reach lower, or must
widen the stance of the lower extremities to bring the upper body
down to the height of the client.8
Between these two choices, widening the stance is preferable; however, it requires greater effort than
simply standing upright. For this
reason, ideal table height will vary
during a treatment session based
upon the work that is being done.
The solution to this dilemma for
anyone who combines deep tissue
work and lighter work on a regular
basis is to use an electric lift table.2,7
While electric lift tables are viewed
as extravagant by many in the bodywork profession, in my opinion, they
are an absolute necessity.
Being able to change the height of
the table during a session by merely pressing on a foot pedal enables
deeper pressure to be delivered with
less effort on a low table, and allows
you to stand straighter when doing lighter work with the table set
higher. This allows for better sessions therapeutically for the client
as well as healthier and less fatiguing sessions for the therapist. In the
long run, the benefits of an electric
lift table far outweigh the increased
cost of the initial purchase.

3b

3c

Figure 3a shows the stoop bend, in which the therapist bends by flexing the spinal joints of
the trunk. Of the three methods of bending, the stoop bend is least healthy for the therapist.
3b shows the squat bend with the trunk inclined forward. 3c shows the squat bend with the
trunk vertical. This bending method is biomechanically the least stressful on the therapists
body and should generally be strived for whenever bending over a client is necessary.

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Guideline No. 2: Less Lubricant

For beginning bodyworkers, the
amount of lubricant used is often
part of the problem. The point of using a lubricant is to allow the therapist to glide along the clients skin
without excessive friction. However,
the more lubricant that is used, the
more the therapists pressure translates into slipping and sliding along
the clients skin instead of delivering
pressure into the clients tissues.

3a

tip:
 mtj/massage therapy journal winter 2006

A good guideline for table

Height is that the top of it
should be no higher than
the top of the knee joint.

The general guideline for lubricant is to use the least amount necessary for the clients comfort. Any
amount greater than this decreases
the efficiency with which pressure is
delivered to the client.
Besides the amount of lubricant,
the type of lubricant can also make
a difference. Generally, oil-based lubricants tend to create more slide
and are not as efficient for deep tissue work as water-based lubricants.

tially flexed and imbalanced trunk

posture.9
Further, a stooped posture of spinal flexion places the spinal joints
in their open-packed position. The
open-packed position of a joint is its
least stable position; therefore muscles must contract to play a greater
role in joint stability. The result is
greater effort on the part of the spinal extensor musculature to maintain the stooped posture.

bending &
massage delivery

Squat Bend
A better alternative is the squat
bend, which is achieved by flexing
the hip and knee joints instead of
the spinal joints. In a squat bend,
the spine stays erect in its closedpacked stable position, which is
healthier for the spine and requires
less stabilization contraction effort
by the spinal extensor musculature.

Guideline No. 3: Bending

While the ideal body posture for
delivering deep pressure with maximal efficiency is for you to be positioned directly above the client and
delivering the force directly downward, this body posture is not usually possible to attain without some
bending on the part of the therapist.
The manner in which the therapist
bends is extremely important because bending tends to create postural imbalances that require effort
to maintain and places stress upon
the therapists body. Bending postures can be divided into two general categories: the stoop bend and
the squat bend.
Stoop Bend
The stoop bend, which involves flexing the trunk at the spinal joints in
an effort to bring the body over the
client, is less healthy for the therapist. This is because it unbalances
the therapists body by moving the
center of weight of the trunk from
being balanced directly over the
pelvis to being unsupported (Figure
3a). In this position, the only reason
that the therapists trunk does not
fall into full flexion is that the spinal
extensor musculature must contract
isometrically to maintain the par-

There are two squat bend methods:

Q Squat bend with the trunk inclined forward;
Q Squat bend with the trunk maintaining its vertical posture.
Between these two, maintaining a
vertically positioned trunk is preferable, as a squat bend with the trunk
inclined forward still places the trunk
in an imbalanced posture in which
its center of weight is unsupported
(Figure 3b). This requires spinal extensor musculature contraction to
prevent the trunk from falling into
flexion, as well as hip joint extensor
musculature contraction to maintain
the flexed anterior tilt posture of
the pelvis at the hip joints.
The squat bend with the trunk
vertically positioned maintains the
trunk in a balanced posture, such
that its center of weight is perfectly
aligned and supported over the pelvis (Figure 3c). This eliminates the

4a

4b

4c

Figure 4 demonstrates the importance of the orientation and alignment of the therapists
trunk. 4a illustrates a long massage stroke that is being done along the spine on the paraspinal musculature. For the body weight of the trunk to be behind the stroke, the alignment of
the trunk must be identical to the line of force of the stroke. 4b and 4c illustrate trunk alignment during application of force to a clients neck with the therapist working from a seated
position. In 4b the therapist is working the clients lower neck; in 4c the therapist is working
the clients upper neck. Note the change in orientation and alignment of the therapists trunk
to match the direction in which the force is being delivered.

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need for spinal extensor musculature contraction to keep the trunk

from falling into flexion and hip
joint extensor musculature to maintain pelvic posture.10
The key to creating a vertical
squat bend instead of an inclined
squat bend is the degree to which
the knee joints are flexed. As the
hip joints are flexed to achieve the
squat bend position, the pelvis anteriorly tilts, inclining the trunk forward. However, the more the knee
joints are flexed as the hip joints are
flexed, the easier it is to keep the
trunk vertical. This is bending with
the knees as we often hear.
Hence, a squat bend with the
trunk vertically aligned maintains
the spine in its most stable closedpacked posture, as well as maintaining the trunk in a balanced and supported posture over the lower body.
This translates to the ability of the
therapist to work and deliver pressure efficiently while maintaining a
healthy spine.
It is interesting that even though
most everyone knows that it is
healthier for our back if we bend
with our knees, so many people do
not follow this advice and instead
fall into a stoop bend. There must
be a reason for this. As it turns out,
while the squat bend is healthier for
the back, it actually requires more
energy expenditure than the stoop
bend.10 Further, even though the
squat bend is healthier for the back,
it does place a greater stress on the
knee joints. All things being equal, it
is usually more important to protect
the spinal joints. However, when applying these bending guidelines to
each particular therapists needs,
the stress upon the knee joints must
be factored in. If a therapist has unhealthy knee joints, a stoop bend
may be the lesser of two evils.

tip:

use the least amount of

lubricant necessary for
the clients comfort. This
will increase the efficiency

5a

5b

Figure 5 shows two positions of the feet when doing bodywork. 5a is the transverse stance
and is optimal when delivering force transversely across the client. 5b is the longitudinal
stance and is optimal when delivering pressure longitudinally up or down the clients body.
The importance of the orientation of the feet is that the trunk and, therefore, core body weight
is usually oriented in the direction that the feet are pointed.

 mtj/massage therapy journal winter 2006

body alignment
& force delivery
Guideline No. 4:
Trunk Alignment
It has been stated that the key to
delivering a strong force is for the
therapist to use the body weight of
the trunk as much as possible. The
importance of positioning of the
trunk was discussed in guideline
one. However, the orientation and
alignment of the trunknot just the
positionare also critically important when looking to efficiently deliver pressure.
As a rule, for body weight to be
behind the pressure that is being
delivered to the client, your trunk
must face the same direction as that
of the pressure being applied. An
easy way to determine the direction your trunk is facing is to look

at your navel. Whatever direction

your navel is facing, your trunk is
facing.
For example, if the force of a soft
tissue stroke is being applied across
the clients body, then your navel
should be facing across the clients
body in the identical direction. If,
on the other hand, the force of the
soft tissue stroke is being applied
longitudinally along the length of
the clients body, then your navel
should be similarly oriented. Figure
4 demonstrates a few examples of
proper orientation and alignment of
the trunk.
Note: Aligning the trunk along the
direction of force is largely a matter of proper positioning of the feet.
This is discussed in more detail in
Guideline No. 5.

Guideline No. 5:
Position of the Feet
Thus far, much has been said about
the importance of the positioning,
orientation and alignment of your
trunk. However, there is an old adage in tennis that goes its all in the
footwork. This is no less true when
doing bodywork. Your footwork is
crucially important, both for aligning
and positioning the trunk, and also
for pushing off to generate pressure.11
To achieve all of these things, lets
look at the placement of the feet.
Generally, the direction that the
feet are facing is the direction that
the trunk is facing. Therefore, if it is
desired to change the orientation of
the trunk, the easiest way to accomplish this is to change the orientation of the feet. Further, if the feet
are not positioned correctly, it is
not possible to generate force from
a lower extremity by plantarflexing
a foot against the ground to push the
body weight into the client.12

6b

6c

Figure 6. In figures 6b and 6c, the feet are staggered in position relative to each other, one
in front and one in back. In 6a, both feet are aligned and parallel to each other. This position is least efficient at generating a forward force into the client. In 6b, they are both facing
approximately forward. in 6c the rear foot is pointed nearly perpendicular to the front foot.
The staggered position of 6b with both feet facing forward is most efficient at generating a
forward force into the client.
clients body because the trunk is
not facing that direction.
On the other hand, the longitudinal stance is effective for delivering
pressure longitudinally along the
clients body because it orients your
trunk to face that way (Figure 5b);
however, its ineffective when working transversely across the clients
body because the trunk is not facing
that direction.
Orientation of the
Therapists Feet
Further discussion is warranted

regarding the precise orientation

of your feet relative to each other.
There is a great deal of argument
over optimal positioning of the feet.
There are three alternate positions
of the feet relative to each other:
Q The feet aligned next to each other and parallel;
Q The feet staggered in position
with both feet facing approximately the same direction (i.e.,
approximately parallel);
Q The feet staggered in position
with the rear foot oriented ap-

It is a sacred maxim in massage therapy that the therapists shoulders should never be up. Is this always true? Please go
to www.amtaonlinelearning.com for the full online version of this article and read more about this. You can also go to www.

www.amtamassage.org/mtj 10

Transverse &
Longitudinal Stances
Positioning of the feet can be divided
into two general categoriestransverse stance and longitudinal stance.
Squaring off the feet perpendicular
to the length of the table is called the
transverse stance and orienting the
feet parallel to the length of the table is called the longitudinal stance.
The transverse stance is effective
for delivering pressure transversely
across the clients body because it
orients your trunk in that direction
(Figure 5a); however, its ineffective
when working longitudinally up the

6a

proximately perpendicular to the

front foot.

11 mtj/massage therapy journal winter 2006

7a

7b
Figure 7 shows two postures of the head
during bodywork. In 7a, the therapist is flexing the neck and head to look at the client.
In 7b, the therapist is holding the head in a
more balanced posture over the trunk. This
posture is least stressful for the massage
therapists body.

Feet Aligned and Parallel

An inherent weakness with the
aligned position of the feet (Figure
6a) is that the base of support created by the feet is not very wide in
the sagittal plane from anterior to
posterior. This makes it difficult to
maintain balance of the upper body
over the feet with movements of the
pelvis and trunk in the sagittal plane
as you lean forward into the client.
For example, if you try to lean into
the client by bringing the pelvis and
trunk forward (bending at the hip
joints), your body will be projected
anterior to the base of the feet and
will not be supported and balanced.
If you compensate for the anterior
weight shift of the trunk by shifting
the weight of the pelvis posteriorly
in an effort to counterbalance the
body, then your overall body weight
shifts posteriorly and is no longer
sufficiently anterior to be over the
clients body; this results in an inability to effectively use body weight
to generate force.
Similarly, the therapist is unbalanced and unsupported in this position if the core of the body is propelled forward by pushing off from
the feet. Either staggered position
of the feet is superior in this regard
because the back foot can be used
to push off the ground and project
the therapists body weight forward,
while the therapists body weight will
still be balanced and supported over
the front foot. Hence, a staggered
position of the feet provides a wide
sagittally oriented stance allowing
for balance of the body between the
rear foot and front foot.3,5
Feet Staggered
Between the two choices of stag-

gered positioning of the feet, having

the rear foot facing approximately
the same direction as the front foot
(Figure 6b) is the superior position
because it places the powerful sagittally oriented ankle joint plantarflexors (soleus and gastrocnemius), knee
joint extensors (quadriceps femoris),
and hip joint extensors (hamstrings
and posterior gluteals) in line with
the direction of the stroke. 7, 12
The position in 6c wherein the
rear foot is oriented markedly differently than the front foot (and indeed
the entire body) loses the orientation of the powerful sagittally oriented musculature just mentioned and
also places the two lower extremities at odds with each other when it
comes to generating force because
they face in different directions.
Moving the Feet
One final note regarding placement
of the feet: There is no rule that
states that the feet must be planted
at the beginning of a stroke and stay
in that planted position for the entirety of the stroke; the feet can be
moved. With a short stroke, there
is little or no need to move the feet.
However, with a longer stroke, if the
feet are not moved, you will have to
reach out horizontally farther away
from the initial base of support of
the feet. This results in not only a
loss of support and balance, but also
an inability to keep the trunk vertical, thereby losing the ability to use
body weight to generate force vertically downward with gravity.

positioning to reduce
injury and maintain force
Guideline No. 6: Head Position
An often-overlooked aspect of body
mechanics is the position of the
therapists neck and head. The position of the neck and head has little

to do with the direct generation and

delivery of force while performing a
massage. Therefore, it makes sense
that the therapist should posturally
hold the neck and head in whatever
position is least stressful.
The healthiest posture is to hold
the head over the trunk so that the
center of weight of the head is balanced over the trunk.7,13 This position requires little or no muscular
effort by neck muscles to support
it. Unfortunately, many therapists
have the habit pattern of flexing the
neck and head at the spinal joints
to look down at their client. This
imbalances the posture of the head
and requires isometric contraction
of the extensor musculature of the
neck to keep the head from falling
anteriorly into flexion.9 Over time,
this leads to pain and spasm in the
posterior neck.
If its necessary for you to look at
the client as a stroke is being done,
then this posture is necessary and
correct to assume. However, most of
the time, there is little or no need
for it; you even can close your eyes
and visualize the structure of the client under your hands. So it is a good
reminder for you to occasionally focus on the posture of your neck and
head to be sure that it is in a posture
that is as easy and relaxed as possible (Figure 7).

8b

8c

Figure 8 demonstrates force delivery through a therapists upper extremities that are stacked
and not stacked. Figure 8a shows a therapist who has the elbow, wrist and thumb joints of the
upper extremities fully stacked. Figure 8b shows a therapist with the elbow joints unstacked
(i.e., flexed). As the force generated in the therapists trunk is transmitted through the flexed
elbow joints, the upper extremity joints tend to collapse resulting in the therapists trunk falling toward the client (Figure 8c).

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Guideline No. 7: Stack Joints

Whether the force behind the stroke
being delivered to the client is created by muscular effort on your part
or is due to using body weight, this
force must be transmitted through
your upper extremity joints (elbow,
wrist, finger, thumb). For this force
to travel through the upper extremity joints without loss of strength,
it is important that the joints are
stackedextended and placed in a

8a

9a

13 mtj/massage therapy journal winter 2006

9b

9c
Figure 9 illustrates three applications of
force into the back of a client. Note how the
direction of the force of the stroke is different
in each case so that it is delivered perpendicular to the contour of the body surface
that is being worked. Applying pressure perpendicular to the body surface contour is the
most efficient delivery of force.

straight line (Figure 8a).2,3 Then you

can deliver pressure for the stroke
in a straight line from the trunk of
the body through the stacked joints
of the upper extremity to the contact with the client.
If you do this as you lean and/or
push into the client by pushing
off with the back foot, there will
be little or no loss of strength, and
less muscular effort is necessary.
However, when your upper extremity joints are not stacked (i.e., they
are flexed), the force generated that
must pass through the upper extremities will probably be lost to the client because there will be a tendency
for the joints of the upper extremity to collapse. Thus, the force that
was supposed to be delivered into
the clients tissues is lost in creating
movement of the therapists body at
the shoulder, elbow and wrist joints.
(Figures 8b and 8c).
It is possible to transmit force
through these unstacked, flexed upper extremity joints without loss of
strength. However, it requires greater effort because muscles around
the unstacked joints must be isometrically contracted to stabilize
the joints, preventing them from collapsing. This results in greater effort
and is less efficient for the therapist.
Note: Even perfectly stacked joints
do not eliminate all effort and stress
to the body. While markedly less
than with unstacked joints, there
will still be some contraction effort on the part of the musculature
to stabilize the stacked joints, and
stacked joints will be under greater
compression forces than when unstacked. However, by keeping the
joints straight inline with the line
of force being transmitted, all force
from your trunk is transmitted without loss of strength to the client.12

stroke performance &

massage delivery
Guideline No. 8: Proximal versus
Distal Generation of Force
It has been stated that utilization of
body weight via the external force of
gravity is recommended whenever
possible because it requires little or
no effort. However, when it is necessary for you to use internal muscular effort to generate the therapeutic
force necessary for the treatment
technique, there is a choice of which
muscles to use.
When choosing between small and
large muscles, it is always advantageous for you to generate the force
using larger muscles of the body.2 A
smaller muscle cannot generate the
same maximal force that a larger
muscle can. Further, to the degree
that a smaller muscle does generate
the same force as a larger muscle,
it requires a much greater effort to
achieve this.
Looking at the muscles of the
upper extremity from distal to
proximal, it is evident that smaller
muscles are located more distally
and larger muscles are located more
proximally. For example, the finger
joint muscles located intrinsically
within the hand are smaller than the
wrist joint muscles located within
the forearm, which are smaller than
the elbow joint muscles located
within the arm, which are smaller
than the shoulder joints muscles located in the trunk. For this reason,
it is recommended whenever possible to generate force proximally
from the trunk.
In addition to the larger proximal
core muscles of the trunk, large muscle groups of the lower extremities
can also be engaged to create great
force with little effort. By placing
the feet appropriately, the therapist
can push off the ground to generate

strength of force that can be delivered into the client. (See Guideline
No. 5 on page 131 for more information about proper positioning of
your feet.)

30

If the angle of your force is 30 degrees off from being

perpendicular to the clients body surface, you lose
approximately 15 percent of your force. If the angle of
your force is 60 degrees from perpendicular, you lose
50 percent of your force!

10a

10b

10c

10d

Figure 10 shows four examples of a double-supported contact of a therapists hands upon

a client. 10a is a double-support of the thumb; 10b is a double-support of the fingers; 10c
is a double-support of the ulnar side of the hand and 10d is a double-support of the palm
of the hand.

www.amtamassage.org/mtj 14

Guideline No. 9:
Direction of Force
When we discussed table height in
Guideline No. 1, it was emphasized
that the most efficient way to use
gravity is for you to direct the force
vertically downward. However, the
body surface of the client that is being worked is not always horizontally flat. Therefore, while a vertically
downward application of force is the
most efficient way to utilize gravity,
it is not always the most efficient
direction to transmit force into the
clients body.
For example, when a client is lying
prone, the clients back has contours
created by the curves of the spinal
column. Taking these contours into
account, the therapist must change
the direction of the line of force so
that it is perpendicular to the contour of the location where the client is being contacted. This means
that you might be pressing into the
clients back at an oblique angle.
There are also times when the
therapist is working horizontally
into the side of the clients body. For
these cases, it is important to realize that the most powerful and efficient delivery of force into the clients body is the force that is applied
perpendicular to the body surface
that is being worked.3,11 Any deviation from perpendicular will involve
some loss of strength and efficiency
because some of the force will be
transmitted into sliding along the
tissue instead of pressing into the
tissue. (Trigonometric formulas for
computing the loss of strength are
available in Hamill and Knutzens

tip:

to protect your hands

against injury, it is
advisable to use the
largest contact surface of
the hand possible.

Biomechanical Basis of Human

Movement, page 276.)
To illustrate this idea, Figure 9
shows three different applications of
force for a therapist working on the
back of a client. Note that in each
case, the force is being applied perpendicular to the contour of the region of the back that is being worked.
If you try this in your practice, I believe that you will intuitively find
it to be the easiest way to generate
pressure with the least effort.
A necessary addendum to this concept is that if a long stroke is being
donefor example, one that covers
the entire length of the spinethe
contours encountered during that
stroke will vary. For maximal efficiency, it is necessary for the therapist to adjust to these contours by
changing the direction of the application of pressure; this necessitates changing the orientation of the
trunk, and likely also necessitates
changing the position of the feet.

15 mtj/massage therapy journal winter 2006

contact area
Guideline No. 10: Choose a
Larger Contact Area
When deep pressure is being delivered, that pressure must be transmitted into the client through whatever body part the therapist uses to
contact the client. Apart from the
occasional use of elbow, forearms,
and feet, bodyworkers usually contact the client with their hands. The
danger is that over time, continually
transmitting deep pressure through
the hands will cause damage to their
relatively small joints.
To protect the therapists hands
against injury, it is advisable to use
the largest contact surface of the
hand possible. For example, working
with the palm of the hand compared
to the fingers or thumb allows for
deeper pressure to be given with less

chance of injury to the therapist.

The disadvantage to using a larger
contact instead of the fingers or
thumb is that larger contacts tend to
be less sensitive, making it more difficult for the therapist to assess both
the quality of the clients tissues and
the response of the client tissues to
the pressure as the massage is being
performed.7
The appropriate contact at any
point during the massage can only
be determined by the therapist. If
you do like to use fingers or thumbs
a lot, I would recommend that you
alternate between these contacts
as often as possible. This allows the
stress load upon the hands to be
spread around, giving each of the
muscles and joints of the hand a
chance to rest.
In addition to choosing a larger
hand contact, it is important to
double-support the contact. This
means that instead of using the two
hands separately to work on the client, the two hands need to work together. One hand should be placed
somewhat over the other so that the
contact hand on the client is stabilized and reinforced by the other
hand (Figure 10).2,7 Another benefit
of double-supporting the contact is
that it strengthens the therapists
contact, allowing for a stronger and
more efficient delivery of force into
the client.
Protecting the contact area of the
hand is particularly needed when
working with smaller contacts,
such as the fingers or thumbs. For
a therapist with a hyperextendable
interphalangeal joint of the thumb,
double-supporting the thumb is critically important to prevent it from
collapsing into hyperextension. Figure 10 illustrates four double-supported contacts of the therapists
hands upon the client.

Summary
No matter what technique and style
of delivery we have, doing massage
is hard work and places physical
stresses on our bodies; we cannot
avoid that reality.7 However, if we
learn to work more efficiently, we
can decrease these stresses.
The proposed guidelines of this
course are meant to help increase
the efficiency of our work and
thereby minimize the stress to our
body. As you practice them, keep
in mind that any change made in
body mechanics will most likely feel
awkward at first simply because it is
different. However, with time, applying these guidelines should become
more comfortable.
While not comprehensive of all
aspects of body mechanics for bodyworkers, these 10 guidelines are a
solid foundation to build upon. It
should be noted that even though
these guidelines were presented and
discussed separately in this course,
it is only by seamlessly weaving
them into a cohesive whole that a
fluid and efficient style for the delivery of bodywork can be achieved.
Further, by increasing the efficiency and decreasing the effort of our
work, the quality of our work will
likely improve as well.14 Increasing
efficiency is learning to work smarter instead of working harder; and
working smarter is the key to having
a long and successful career.
n

2. Clay J, Pounds D. Basic Clinical Massage Therapy Integrating Anatomy

and Treatment. Lippincott Williams &
Wilkins: Philadelphia, 2003.
3. Fritz S. Fundamentals of Therapeutic
Massage, 3rd ed. Mosby of Elsevier
Science: St. Louis, 2004.
4. Levangie P, Norkin C. Joint Structure
and Function, 3rd ed. FA Davis Company: Philadelphia, 2001.
5. Peterson D, Bergmann T. Chiropractic Technique Principles and Procedures, 2nd ed. Mosby of Elsevier Science: St. Louis, 2002.
6. Foster MA. A Case for the Human
Stance. Massage and Bodywork.
2005 Apr//May: 72-81.
7. Frye B. Body Mechanics for Manual
Therapists, 2nd ed. Fryetag Publications: Stanwood, Washington: 2004.
8. Peterson D, Bergmann T. Chiropractic Technique Principles and Procedures, 2nd ed. Mosby of Elsevier Science: St. Louis, 2002.
9. Nordin M, Frankel V. Basic Biomechanics of the Musculoskeletal System, 3rd ed. Lippincott Williams &
Wilkins: Philadelphia, 2001.
10. Neumann D. Kinesiology of the Musculoskeletal System. Mosby of Elsevier Science: St. Louis, 2002.
11. Luttgens K, Deutsch H, Hamilton N.
Kinesiology Scientific Basis of Human Motion, 8th ed. William C Brown:
Madison, 1992.
12. Hamill J, Knutzen K. Biomechanical
Basis of Human Movement, 2nd ed.
Lippincott Williams & Wilkins: Philadelphia, 2003.
13. Muscolino J. Kinesiology The Skeletal
System and Muscle Function. Mosby
of Elsevier Science: St. Louis, 2006.
14. Myers T. Anatomy Trains. Churchill
Livingstone of Elsevier Science: Edinburgh, 2002.

Still want more information on proper body mechanics? Read additional content from this CE course exclusively onlne at
www.amtamassage.org/mtj. Just click on the Online Exclusives link.

www.amtamassage.org/mtj 16

References
1. American Massage Therapy Association. 2005 Massage Therapy: Industry
Fact Sheet. 23 Jan 2006. AMTA. 25

Sept 2006 [www.amtamassage.org/

pdf/2005MTIndustryFactSheet.pdf].