Considerations for improving your manual therapy, Part Two

As a massage therapist, I feel fortunate to also be trained in the science of improving human movement—strength and conditioning—as it affords me a wider lens to look through when treating and assessing soft-tissue on the table.  This allows me to think beyond increasing range of motion, or decreasing muscular stiffness in isolation, on the table, and in a more global, functional context. 

Those who have worked with me understand the emphasis I place on optimal movement and although I’ve been impressed by massage therapist’s knowledge of muscle actions and attachments, I often feel that something is still missing. Being able to palpate tissue tension is important, of course, but understanding the issues that underlie that tension in the first place is the art behind the science.

With that said, and as a follow up to last year’s article, here are six principles I always consider during assessment and treatment that have greatly improved my treatments and client success rates.

We’re All Asymmetrical

We are all inherently asymmetric beings.  Our diaphragm has more and stronger attachments to our spine on the right side.  Our heart is positioned more in the left chest wall, than the right.  Our liver sits under our right diaphragm, giving it more structural support to aid in respiration than our left diaphragm.  The left side of our brain—which controls the right side of our body—houses the majority of our motor control function. This along with our breathing patterns and the polyarticular chains of muscle that animate our anatomy with movement are all constantly shifting us towards the right side of our body.

This realization forces you to distinguish between “neutral” and “symmetrical.” You can be asymmetrical, which we all are, and still be neutral.  Due to life’s continual stressors and one’s preference of activity or sport, some humans tend to fall more into these asymmetrical patterns than others.  It’s important to realize that these asymmetries exist, and to take them into account when assessing and treating.

To learn more on this topic check out the Postural Restoration Institute.

The Joint-By-Joint Approach

This holistic way of looking at the human body was popularized by Physical Therapist Gray Cook.  At its very root, the joint-by-joint approach is a means of viewing the body more globally, as an interdependent stack of joints with alternating needs for stability and mobility.  Understanding the kinetic chain in this way helps you to avoid falling into the mental trap of always assuming that the site of pain is also its source, which is rarely true; and putting tape over a leaking hose will only solve your problems temporarily.

In the above picture we see this alternating stability-mobility pattern.  Starting at the foot we see the need to lots of stability from which the mobility of our ankle joint can be expressed and transferred to the knee, which, in turn, must have requisite stability to absorb that force and transfer it to the hip, and likewise up the chain. 

Treat and train Proximal to Distal

When it comes to training clients for health and performance it is crucial to create proximal stability in order for them to have success in their programs. This concept is easier to understand when you take another look at PRI Principles or the joint-by-joint approach.  Working from the inside out means that you should worry about what is taking place at the core and pelvis first, then get nit-picky about more distal structures.  It’s been said a million times before and I’ll gladly repeat it.

“You can’t shoot a cannon from a canoe”

Treat client’s with this in mind and refer to a skilled strength coach or physical therapist to educate them on how to monitor their spinal and pelvic position during movement of their extremities.  After, you’ll be amazed as to how much sloppy movement improves and how pain dissolves distally.


Typical massage therapist conversation with client prior to session:

LMT: How are you feeling today?

Client: My hamstrings feel tight?

Post-treatment discussion:

LMT: Are you noticing any changes after the session?

Client: I feel looser

Getting some people to feel “looser” is a good thing.  But, getting others loose is only making them worse.  Every one of us has had a client tell us that they feel “tight.”

But, not all tightness is created equal.  Here a few reasons why someone may feel tight:

– True Muscular shortness
– Protective tension
– Neural tension
– Previous injury
– Soft tissue restriction: Adhesions, Scar tissue, trigger points
– Bony Blocks
– Poor Breathing Patterns
– Lack of stiffness at adjacent joints

Believe it or not, my client’s who claim to be the “tightest” are often the most mobile. As a massage therapist, the ability to screen for ligamentous laxity is extremely valuable.  Just because a client is loose jointed doesn’t mean they can’t feel “tight” due to protective and neural tension or trigger point development. A simple screen I’ll use is the Beighton Laxity Scale.

You should be cautious of stretching this type of client. Instead, refer out to an intelligent strength coach or physical therapist that can help the client develop more active stability that can in turn eliminate protective and neural tension as well as trigger points that have formed as sources of stability.

To learn more about what to do with this score from a strength-training standpoint check out this article by PPT’s Sam Sturgis.

The Optimal Performance Pyramid

I was first exposed to the performance pyramid when reading Gray Cook’s book Movement.  In it he explains how movement is the base of everything and that once a strong foundation of quality movement is constructed one can add power and specific skill on top of that.

That makes sense. But, why should a massage therapist see the importance of this?

There are two reasons why a massage therapist should understand the image above. First, I feel that below functional movement should be another layer, tissue quality. Poor tissue quality or a lack of extensibility must first be treated before you can move through full ranges of motion or learn to develop optimal stability and motor control. To make you think a little more I would even add a larger layer as the base titled neutrality.

Second, even if you’re not working with athletes don’t all of our clients have goals? Don’t they all want to return to doing something that they love? Most often what they love is a specific skill. It could be playing a round of golf each weekend or running around with his or her grandchildren in the backyard.

Think of the above image with the added layers of  “Neutrality” and “Tissue Quality” and it may be easier to see where your manual skills best fit into improving one’s plan for optimal performance.  

Promote the Parasympathetic 


The brain is the ruler of all tissues and the state of one’s nervous system must be taken into account. I’ve found that those who are in pain, especially chronic pain, are often in a state sympathetic overdrive, or consistently in fight or flight mode. If you are fortunate enough to have say in a client’s manual therapy and training programs consider utilizing more parasympathetic dominant training modalities. Check out the list below for common recovery modalities that I use.

– Meditation
– Increased frequency of massage therapy
– Active recovery days (low intensity aerobic training at a heart rate between 120-150 bpm)
– Utilization of breathing and repositioning exercises emphasizing fully exhaling and pauses.
– Foam Rolling
– Improve sleeping environment and/or increase hours of sleep
– Reducing training intensity

If massage and manual therapists can begin to develop a strong appreciation for the above principles your treatments will greatly improve, and your client’s will be able to find success much sooner.

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