Breathing, Positions & Blood Clots: Doing No Harm with Prenatal and Postpartum Massage Therapy During the Coronavirus Pandemic

Some of us are rejoicing as we reopen our adjusted massage therapy practices to COVID-19 realities. Others reopened and now have reclosed their practices as infection rates soar across the United States. Many of us are not ready to go back or are still restricted by local and/or state health mandates. Whatever your status, it is imperative you get ready for that next client—whether that’s tomorrow or next month—and be prepared for how to work with them during the new circumstances brought on by the COVID-19 pandemic. For those therapists who work with prenatal and postpartum clients, this is especially important.

First though, a note: This article will NOT be covering necessary changes to your environment, policies, information collection, hygiene, etc., that are so thoroughly discussed elsewhere. ABMP has informative, practical input for you on their website,1 as do most state associations and credentialing agencies. Also, stay current with the Occupational Safety and Health Administration (OSHA),2 the National Institutes of Health,3 the Centers for Disease Control and Prevention (CDC),4 and your local jurisdictions for up-to-date guidance relevant to massage therapy).

Some of these agencies offer evolving data on the pandemic’s specific impact during pregnancy, labor, and postpartum. I have combined information from these agencies and from Evidence Based Birth,5 American College of Obstetricians and Gynecologists,6 Midwives Alliance of North America,7 the CDC, and other comparable agencies in other countries, resulting in a well-rounded perspective on COVID-19 and childbearing.

From these sources during late July 2020, it appears that:

  • Pregnant women with COVID-19 may be more likely than nonpregnant women with COVID-19 to need care in an intensive care unit (ICU) or need a ventilator (for breathing support).
  • Pregnant women who are Black, Hispanic, or Asian may have a higher risk of severe illness or need ICU care more often than other pregnant women. This is likely caused by social and economic inequity, not biological differences.
  • Although the risk of needing more care in the hospital and having more severe illness may be increased, the overall risk of these outcomes is still low for pregnant women.
  • The risk of death is not higher for pregnant women with COVID-19 than for nonpregnant women with COVID-19.
  • Some pregnant women with COVID-19 have had preterm births, but it is not clear whether the preterm births were because of COVID-19.
  • Researchers have found a few cases of COVID-19 that may have passed to a fetus during pregnancy, but this seems to be rare.

While some of this information is reassuring, pregnant women are disproportionately affected by respiratory illnesses in general, and thus they may be at higher risk for contracting COVID-19. Managing your practice hygiene then is critical.

Physiological and mechanical changes in pregnancy increase susceptibility to infections in general, particularly when the cardiorespiratory system is affected, and encourage rapid progression to respiratory failure.8 As data gradually emerge regarding the effects of COVID-19 infection on pregnant, birthing, and postpartum people, the implications for us when they become our clients evolves too, and it is likely to remain ambiguous and incomplete. If you are seeing childbearing massage therapy clients, staying currently informed is an ethical imperative.

Not So Fast to the Treatment Room

Coronavirus or not, pregnancy’s common companions of back, pelvic, and hip pain continue to bring clients seeking relief from our work. And the additional stress of the pandemic for those expecting a baby can be overwhelming. Regardless of need, any expectant clients with COVID-19 symptoms, presumed or suspected infection, or positive test results should not be receiving massage therapy while ill or contagious. If they had credible exposure, they should undergo 14 days of isolation to prevent spread if they are infected. Because of the varied severity of symptoms and recovery time, best practice is to seek medical or midwifery review of every pregnant client’s unique condition and request any massage therapy limitations or contraindications specific to that person. Even with that clearance, you may want to delay for at least three months after illness.

Unfortunately, with the high rate of asymptomatic infection and the testing limitations, your clients and/or you may or may not be infected at any point in your treatment interactions. Consequently, I believe it is most responsible to modify all maternity massage therapy protocols as though each expectant or new-mother client has, or has had, this infection. Adaptations for respiratory and placental efficiency and the prevalence of blood clots have always been critical factors with pregnant and postpartum massage therapy clients, even prior to the emergence of the coronavirus. COVID-19 appears to increase these concerns significantly. Let’s next consider these respiratory, positioning, and blood-clotting factors and the ramifications for safe practice.

Respiration, Placental Function, and Positioning

A common, though not universal, symptom of COVID-19 is shortness of breath. As a result, be sure to assess and think through positioning’s effect on maternal and fetal oxygenation for each individual. Common nursing practice9 and obstetrical research10 point to side-lying positioning during pregnancy, left or right, resulting in better maternal and fetal oxygenation and outcomes when compared to other positions. There is a slight advantage to the left side-lying position over the right that, in normally progressing pregnancies, is usually irrelevant.

With coronavirus, however, a recent small study showed some negative effects and compromise in placental functioning when expectant people are infected.11 As of yet, there is no data regarding how long after infection this reduction in placental function may last.

Recommended Side-Lying Positioning Guidelines

With these considerations in mind, I now recommend the following regarding side-lying positioning:

  • Use left side-lying exclusively or for most of a given session, especially if other respiratory compromises are evident, such as shortness of breath (not illness related), postural breathing restrictions, or obesity; asthma, respiratory allergies, or a cold; multiple gestation; other placental abnormalities; or gestational hypertensive disorders (Image 1).

  • Use left and right side-lying positioning with clients who do NOT have any of the compromises listed above and whose pregnancies are proceeding normally.
  • After COVID-19 recovery, continue using left side-lying exclusively, or almost exclusively, unless you consult with the client’s physician or midwife for other positioning clearance, since ongoing placental effects are still undetermined.

Recommended Supine Positioning Guidelines

If you work with a pregnant client in the supine position, then prevention of supine hypotensive syndrome is of increased importance, especially since your client may be asymptomatic and/or untested. Supine hypotensive syndrome is decreased blood pressure caused by the enlarged uterus compressing the inferior vena cava sufficiently to reduce venous return. Symptoms include uneasiness, dizziness, weakness, nausea, shortness of breath, or other discomforts when clients are lying flat on their back, although some report no symptoms (Image 2).

 

 

I recommend a strict adherence to the following positioning guidelines for all your pregnant clients.

  • Limit any supine time to 3–5 minutes if you do not make one of these positioning adaptations.
  • From weeks 13 to 22, adapt supine positioning by placing a wedge under the client’s right lower torso for singleton gestation; after 12 weeks with multiples (Image 3).

 

 

 

 

 

 

 

 

  • After 22 weeks, only use semi-reclining and side-lying positions (Image 4).

 

 

 

 

 

 

If you are well-trained to work with pregnant clients, then providing stable, aligned positioning in side-lying, supine, or semi-reclining is second nature to you. Of course, those therapists already skilled in side-lying positioning will also have that side-lying advantage with all clients, providing an alternative that keeps therapist and client from breathing face-to-face as necessitated when the client is supine.

Blood Clot Considerations

Changes in clot-dissolving capacity occur in all pregnancies and are a normal and protective adaptation to avoid birth and postpartum hemorrhage. Safe perinatal massage therapy always requires taking precautions relevant to possible blood clots. Research points to approximately double the coagulation activity during pregnancy when compared to nonpregnant women, and a tendency toward formation of deep vein thrombosis (DVT) where clots form in the inguinal, femoral, and saphenous veins.12 DVT is even more common postpartum, particularly for those who had cesarean births, other surgeries, or who hemorrhaged. Those expectant and postpartum individuals who are on bed rest are especially prone to clot production; that risk also exists for people who smoke, are over 35 years old, have varicose veins, have recently used birth control pills, are obese, have lupus, have been pregnant multiple times before, or are carrying multiples.

If you are not fully educated about the physiology of normal and high-risk pregnancy- and postpartum-related hypercoagulation and guidelines to reduce chances of thrombi moving from the legs into general circulation during pregnancy and early postpartum, now’s the time to learn, and wait to work with these clients until you do. The accompanying illustration offers a very quick review of the most relevant massage therapy adaptations to reduce complications related to hypercoagulation during pregnancy, especially those relevant for the legs (Image 5). Do not consider looking at this image as adequate education on this critical topic.

 

The restrictions summarized in this illustration are aimed to reduce possible pulmonary embolisms (clots that have traveled from elsewhere that obstruct vessels in the lungs). It is critical you follow thesefor ALL prenatal and postpartum massage therapy clients, regardless of COVID-19. Of course, you alsoshould observe your clients for any of the characteristic symptoms of leg thrombi—increased edema in the foot and/or leg (often unilaterally), localized swelling, heat, redness, and painful, achy legs that can be tender with palpable, ropy veins. These symptoms are particularly worrisome if they increase when your client walks. But to be clear, legs that are painful or achy are a hallmark of pregnancy, so these symptoms alone do not guarantee a blood clot. A clear determination of the presence of clots is also difficult because thrombi are often asymptomatic.13 Given the increased likelihood that blood will coagulate in pregnancy and postpartum, the difficulty in determining the presence of clots, and the potential harm of freely circulating clots, it seems prudent to treat all pregnant and postpartum clients as though they have leg clots. For many decades, pre-coronavirus pandemic, we recommended observing the summarized guidelines in Image 5 throughout pregnancy and with postpartum clients for at least 8–10 weeks after birth. The emerging data about blood clots and COVID-19 is sobering, particularly when added to existing clot dangers during pregnancy and postpartum. Coagulopathy in COVID-19 is a disruption in blood-clotting mechanisms that can appear as organ damage, strokes, heart attacks, pulmonary embolisms, rashes, and COVID-toe, with bumps, swelling or redness as evidence of excessive bleeding and clotting in small vessels (microthrombosis).

Hypercoagulation during and after this illness further reinforces the contraindication that expectant and postpartum clients with COVID-19 symptoms, suspected infection, or positive test results should not be receiving massage therapy while ill or contagious. Furthermore, because of the varied severity of symptoms and recovery time, and the unknowns related to childbearing, I recommend you seek medical or midwifery review of everyone’s unique condition to request any massage therapy limitations or contraindications for that client.

For those cleared for massage therapy, be sure to assess thoroughly for COVID-19 specific manifestations, whether they have had the illness, what was its severity, and any subsequent recovery concerns.

Recommended Blood-Clotting Guidelines

For clients who have had COVID-19 and are seeking massage, these are my best recommendations.

  • Most conservative—wait at least three months for any massage
  • Less conservative—wait at least three months for any massage of the legs or lower abdomen
  • Least conservative—but still probably safe for most within the three-month after-phase: strict adherence to leg massage limitations and guidelines, summarized in Image 5. Most importantly, work superficially (light oil and pressure) on the medial side of the entire leg and into the inguinal area. In addition, be cautious anywhere else major arteries and veins reside, including the neck and axilla, and be judicious about using deep pressure there.

If you do not understand fully the underlying physiological mechanisms and these guidelines, I urge you to delay working with pregnant and postpartum clients until you further educate yourself.

Can Massage Therapy Safely Help?

Absolutely! Despite all these increased precautions and limitations, expectant and postpartum clients may find great relief from skilled massage therapy, beginning with reducing the negative effects of this stress-saturated pandemic.

The following articles fully articulate these concerns as they affect massage therapy in general, and it is critical you understand this information. Read all of them prior to working with pregnant and postpartum clients while COVID-19 is still spreading as part of your “first, do no harm” imperative.

Editor’s note: Portions of this article are excerpted from the third edition of Pre- and Perinatal Massage Therapy by Carole Osborne, Michele Holland, and David M. Lobenstine. Projected publication is December 2020/January 2021 by Handspring Publishing.

Notes

  1. Associated Bodywork & Massage Professionals, “COVID-19 Updates for the Massage Profession,” accessed July 2020, www.abmp.com/covid-updates.
  2. Occupational Safety and Health Administration, “Guidance on Preparing Workplaces for COVID-19,” accessed July 2020, www.osha.gov/Publications/OSHA3990.pdf.
  3. National Institutes of Health, “Special Considerations in Pregnancy and Post-Delivery,” accessed July 2020, www.covid19treatmentguidelines.nih.gov/special-populations/pregnancy-and-post-delivery.
  4. Centers for Disease Control and Prevention, “Considerations for Inpatient Obstetric Healthcare Settings,” accessed July 2020, www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html.
  5. Evidence Based Birth, “Coronavirus COVID-19/Evidence Based Birth Resource Page,” accessed July 2020, www.evidencebasedbirth.com/covid19.
  6. American College of Obstetricians and Gynecologists, “Coronavirus (COVID-19), Pregnancy, and Breastfeeding: A Message for Patients,” accessed July 2020, www.acog.org/patient-resources/faqs/pregnancy/coronavirus-pregnancy-and-breastfeeding#How%20does%20COVID19%20affect%20pregnant%20women.
  7. Midwives Alliance North America, accessed July 2020, www.mana.org.
  8. P. Dashraath et al., “Coronavirus Disease 2019 (COVID-19) Pandemic and Pregnancy,” American Journal of Obstetrics and Gynecology 222, no. 6 (June 2020): 521–31, www.ajog.org/article/S0002-9378(20)30343-4/fulltext.
  9. Susan Ricci, Essentials of Maternity, Newborn, and Women’s Health Nursing, 4th ed. (Baltimore: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2017).
  10. R. Silver et al., “Prospective Evaluation of Maternal Sleep Position Through 30 Weeks of Gestation and Adverse Pregnancy Outcomes,” Obstetrics & Gynecology 134, no. 4 (October 2019): 667–76, https://doi.org/10.1097/AOG.0000000000003458.
  11. E. Shanes et al., “Placental Pathology in COVID-19,” American Journal of Clinical Pathology 154, no. 1 (July 2020), https://doi.org/10.1093/ajcp/aqaa089.
  12. P. Devis and M. G. Knuttinen, “Deep Venous Thrombosis in Pregnancy: Incidence, Pathogenesis and Endovascular Management,” Cardiovascular Diagnosis and Therapy 7 (December 2017): S309–S319,
    www.ncbi.nlm.nih.gov/pmc/articles/PMC5778511.
  13. T. Callahan and A. Caughey, Obstetrics and Gynecology (Baltimore: Lippincott Williams & Wilkins, 2007).

 

/by

Bearing Witness to Life and Death, Reflection #1

What a year of transformation, transition, grief and joy!  Three deaths close to my heart…. my first grandchild’s birth… a new home…. an unsettling election process.  Oh, I have been tested and refined by 2016!

During and in its aftermath, questions abound: Can I adapt and go with the flow of even THIS? How can I stay grounded, open-hearted and find joy in the moment when fear, loss and anger swirl in me and around me?  How do I use my therapist skills to assist the journey towards one’s first or last breath? Who is nurtured more, me or them, by these weekly days with the new family? By this wiped brow or that spine rocked? What deepens my restoration and furthers my new home as sanctuary? How do I stay focused and effective in my inner and outer work? What right actions and words encourage Unity and dialogue rather than hostility? What can my process add to my inner evolution and to that of my students, clients and colleagues?

It’s that last question that leads me to this and several future blog posts. I frequently write to understand and clear my heart and mind.  Also, whenever I offer tidbits of 2016’s  challenges and insights, inevitably I hear, “your sharing that is so helpful to me.” And so, with helpful intentions for you and me….

My Children’s Father

The ten years’ distance after divorce almost disappeared during my children’s father’s illness and death. For 15 months, Andy traversed his trail through lung cancer to his death in May. His current wife, step-daughter and our son, daughter and their partners that were rightfully the ones by his side. From my amiable but appropriate distance, I sent encouragement as well as solicited and unsolicited advice. I joined everyone’s delight when 10 months of treatment appeared to make him a poster child for chemotherapy’s best promises of extending his life. I took as priority my role as supporter of our children through this.

When a nagging pain, diagnosed as a hip flexor strain suffered while captaining a sailboat, began curtailing Andy’s gusto for his remaining life, all involved navigated the complexities of his receiving bodywork from me. This was finally assistance that I was eminently qualified to give, despite only basic knowledge in massage for those with cancer. (Thank you, again, Tracy Walton, for your excellent course oh- those- many- years ago!)

Ethics and Healing Touch

Working with Andy required my best in boundary management, scope of practice, relationship dynamics, and focus. I mostly was able to be satisfied with breath and movement improvement rather than to feel heroically responsible for saving my children from the loss of their dad. Fairly consistently, I restrained my urges to advise him about supplements or to nag him about what I would do. Instead I focused on maximizing the myofascial and autonomic benefits of our work. Together we created a remarkable balance between physical familiarity and professional connection. Sometimes I wandered mentally into the what- ifs, fears or memories of our shared history. That’s when I cleared my inner eye, returned to his breath and mine as the moment’s reality and asked his tissue and his Being, “How is this now?” He usually enjoyed some 12-32 hours of pain reduction.

A revised diagnosis of bone metastasis soon explained why the dwindling relief. To say that information devastated everyone is an understatement; however, those precious three sessions were uplifting on many levels. He talked of the relief in feeling treatment hands that were seeking to comfort and to know rather than to prod or eradicate. Brief as they were, he called those post-session hours of less pain “vacations” that tremendously enhanced his remaining time.

For me, serving him in this professional way further refined my practitioner abilities. It also was a soothing salve on old wounds. Those three hours echo in me as shining testimony to the power of touch to bridge inner and outer distance and differences in the name of a Higher Love. It’s what we do with each client, but it’s ironically often too complicated and almost impossible to achieve with someone so close.

Choices and Lessons

When Andy chose to end his life a few short months later, that emotional gulf widened again exponentially, remaining still to be fully crossed. In the immediate aftermath, my inner mother bear roared endlessly. She remains vigilant that her wounded cubs be protected from further harm. She’s sometimes still enraged that she can’t prevent what’s already happened yet determined that his is the only life that Andy has the authority to take.  I continue to put my attention on realizing that intention as much as possible.

Every spiritual, philosophical and relationship fundamental I counted on was put into question as I wrestled with suicide’s many facets. For months I was often exhausted, ultra vulnerable, and sometimes slammed around between conflicting feelings. Occasionally I got ambushed into physical sensations and emotional turmoil that I thought I had resolved years ago. Most things took more time and effort. I was on a physical and emotional roller coaster seemingly not of my choosing.

Fortunately there were several months before I had to sustain four days of teaching. Because my usual focused, productive self only occasionally briefly emerged, I would ride those fleeting times like the wind. Then I would maximize my joy while attending to many languishing work commitments and desires and to seeing a few clients. Often it was the meditative focus of doing a session or teaching a workshop that most grounded me to the Eternal realities rather than being swept off my feet in the emotional tides.

(Throughout all of this, the needs of my dear friend and housemate who also was walking his own unique journey with metastasized cancer were a similar blessing and trial, but that’s a whole other blog post to come.)

I have coped reasonably well with multiple transitions this year. How? Decades of developing my inner and outer strength, I think, and by recognizing that others endure far more with dignity and effectiveness – by retaining my daily tai chi practice – resuming psychotherapy – regular bodywork and acupuncture – increased walking, dancing, meditation and sleep. Whenever safe to, I yielded to the gradually lessening yet always cleansing waves of crying/screaming/shaking/coughing release. I regularly sought the comfort of my sweetheart’s gentle calmness, my decades-long friends’ listening ears and wisdom and my children’s familiarity. I prioritized their heightened needs; my son’s baby was a few months away from his birth. (third blog post in this series to come), and my daughter was newly engaged. Both of these exquisite delights were also poignant reminders that they miss their father terribly, and always will.

I emerged from Andy’s end of life a humbled and determined single parent. I am more experienced with ethical nuances and maddening impossibilities both professionally and personally. I am a more empathetic, refined therapist. Lessons in letting go, death and self-responsibility have enriched me. I know better the vast distances and infinite closeness between us all.

With Gratitude

Writing helps to create resolution for me; you remember that? Maybe not, as this is such a long post; however, since you are still reading this, finally, I want to share a related, profoundly healing piece that mostly I wrote in the month after Andy’s death. I’d like for you to know more of this unique man who fathered my children, accompanied me during some of the most productive and enriching years of my life, and continues to offer lessons in loving far after his last sunset here on earth.

(Remember to check back into this blog in a few weeks for Bearing Witness to Life and Death, Reflection #2)

 Andrew Albert Sheets (1948-2016), age 67, set his final sails on May 26, 2016. The hearts of his wife Francine Martinez, his children Josh Sheets, Elizabeth Gladys, and Elizabeth Martinez, his granddaughter Peyton Martinez, and many dear friends and other family will forever harbor his love.

Born and raised in Monroe, Michigan, Andy hunted, ice skated and read his way through childhood to graduate from Jefferson High School. After serving four years in the Navy, primarily off the coast of Vietnam on the USS Enterprise, he made San Diego his new home, finding community with his spiritual brothers and sisters of the Arica Institute.

For work, he pursued electronics, scuba diving, computer engineering, massage therapy, and, finally, sailing, becoming an exuberant captain, instructor and director of education at Seaforth Boat Rentals. His role as a mentor and teacher is one of his legacies; he was diligent, caring, empathetic and flexible in helping them to “find their path” in any given task. On or in the ocean, he relaxed, thrived, and adventured, rejoicing in teaching others with patience and skill.  He couldn’t resist seeing what was around the next bend, over the summit of a mountain, at the end of a desert trail, or in a book’s last chapters. He delighted in repurposing and engineering various materials into useful or entertaining creations: a tube to serve as a sword or kitty toy; a portable shower for desert camping; a toddler’s slide or tunnel chamber from a shipping box.

Andy was above all else a family man.  As a young man, he met Ann Leahy and was introduced to the love and joy family can bring. For the five Leahy children, he stepped into the role of  “that father we always wanted” to many of them.  He allowed himself to grow in this father role, readying him for his time with his own children, Josh and Elizabeth (the Elder). Together with their mother, Carole Osborne, he found a love through his children that was real and fulfilling. His reputation with his children’s friends was found in  role-playing games or leading hide-in-the-dark tag, his imagination, playfulness, resourcefulness, devotion, tailoring and baking (oh, that bread, those pies, those pecan rolls!).

His presence obviously reached fruition in Josh and Elizabeth’s happy, successful lives, but he still had another child ahead.

Andy found a new love in Francine Martinez, expanding his family as he knew it.  A second daughter emerged from that marriage as he and Francine’s daughter, Elizabeth (the Younger), bonded as father-daughter, finding in each other a kindred spirit. With the expanded family, he now became the consummate host, introducing barbecued/smoked meals and spirit exploration, competitive card games and hours of Sunday football filled with laughter and lively banter.

Andy also embraced his role as grandfather. His mischief and playfulness with his granddaughter, Peyton, brought a new light to his eyes and a sparkle that will not be forgotten.  His enormous bear hugs, tickles and playfulness he shared with Peyton will be passed on to his future grandchildren with zest and accompanied by stories of “Papa”.

To Andy we say, “Sail on.”

/by

The Pregnant Pelvis – An Introduction to Safe, Effective Prenatal Massage Therapy

NOTE: The following article is intended to present the massage therapist/bodyworker safe, effective guidelines for addressing the most common pregnancy complaint, lumbar and pelvic pain. Sections of this article are excerpted from, Pre- and Perinatal Massage Therapy, which forms the theoretical foundation of the 4-day course developed by Carole Osborne. This article was originally published in Massage Magazine, Summer 1998 issue.

Pelvic and Lumbar Pain During Pregnancy

In a 1994 survey of prenatal massage therapists, they cited relief from pregnancy aches and pains as a primary motivator for their clients seeking therapy. 1 Studies conducted in Sweden reported 48-56% of all pregnant women experience backache during pregnancy. They described this pain as generalized fatigue, tightness, and achiness with concentrated areas of pain. Half of these women suffered discomfort in the sacroiliac area. Another 25% complained about the lower back while the upper back was most problematic for another quarter of these subjects. Many women found months 5-9 most uncomfortable, and many reported their first incidence of chronic pelvic and back pain during a pregnancy. 2

Back and pelvic pain secondary to pregnancy is the result of: improper posture created by the anterior weight load of enlarging breasts, uterus, and fetus; muscle strain and imbalance; myofascial trigger points; fetal positioning; hormonal effects on ligaments; referred pain from uterine ligaments. 3

Prenatal Posture and Structural Integrity

The shift in center of gravity created by more anterior weight in the breasts and abdomen challenges a pregnant woman’s structural integrity. As pregnancy progresses her pelvis will inevitably rotate anteriorly, spilling the uterus forward against the abdominal walls. This misalignment increases the lumbar curvature and stretches and weakens all of the abdominal muscles. Pressure against the interior abdominal walls subsequently both separates the rectus abdominus at the linea alba (diastus recti) and incites hyperirritable, tender points (myofascial trigger points) in the abdominal muscles that characteristically refer pain posteriorly. In compensation for lumbar and pelvic misalignment, her head and neck jut forward anterior of the optimal vertical line; she leans her upper ribcage more posteriorly; and her pectoral girdle sags into forward rotation.

Struggling against the increasing weight, all of her posterior musculature becomes fatigued, tight, and fibrotic, and posterior trigger points flourish. Increased abdominal and overall weight also encourages external rotation of her hip joints and loss of iliopsoas function in walking, resulting in pregnancy’s characteristic waddling gait. To prevent falling forward with the increased anterior weight, her knees hyperextend, and her calves frequently cramp. She tends to collapse her increased weight into the medial arches of her weary feet. 4 A fetus with a left or right preference in uterine position often overburdens the favored side of the back making it tired and sore with the unbalanced weight load. Some women develop temporary or permanent scoliosis from fetal positioning preferences.

These postural adjustments to pregnancy result in strain and pain in the following muscles and muscle groups: levator scapulae, sternocleidomastoid, trapezius, and supraspinatus; pectoralis major and minor; abdominal group; erector spinae, multifidi, rotatores, quadratus lumborum, iliopsoas; pelvic floor muscles; hip rotators, adductors, quadriceps group; gastrocnemius, soleus, and peroneals.

Stressed by the anterior load and an average weight gain of 25 to 35 pounds, the weight-bearing joints and associated myofascial structures of pregnant women are strained and compressed. Greatest impact is felt in the intervertebral and facet joints, particularly in the lumbar spine; lumbosacral joint; sacroiliac joints; pubis symphysis; and hip joints. All of these strains are multiplied if a woman exceeds this recommended weight gain.

Most importantly, the relationship of the ilea and sacrum at the sacroiliac joint shifts when the enlarged abdomen protrudes anteriorly. As the pelvis anteriorly rotates, the ligaments of these deep pelvic joints are compressed, strained, and can become hyper or hypomobile in response. Sacroiliac pain is typified by a chronic achiness in the upper, medial quadrant of the buttocks, across the iliac crest, or at the posterior iliac spine of the pelvis, and radiating for several inches. Prolonged periods of standing or sitting, high heels, and poor seated back support, can all create additional strain to these joints. Occasionally one sacroiliac joint’s hypomobility will result in excessive mobility in the other. A sharp, stabbing posterior pelvic pain is then often experienced when rolling from a supine position, particularly on hard surfaces. 5 The lumbosacral junction is similarly affected by increased anterior weight load. Achiness in the center of the sacral and lumbar areas often indicates strain and compression of the lumbosacral joint.

Hormonal Influences on Back and Pelvic Pain

As early as the tenth week, the pregnancy hormone, relaxin, begins softening connective tissues in preparation for labor. Intended to increase the parameters of the pelvic outlet, relaxin is, however, systemic in its effect. The resulting laxity in all ligaments, tendons, and fascia throughout the body contributes to joint instability and more strain on weightbearing structures, especially in the lumbar spine and pelvis.

Probably relaxin’s most detrimental prenatal effect is on the symphysis pubis. Softened by relaxin, this pelvic junction of the pubic bones is vulnerable to horizontal sheering strains that are excruciating when one side of the pelvis is elevated or depressed. Sharp, stabbing pain in the center of the anterior pelvis occurs particularly when rolling over in bed or on a therapy table, climbing stairs, or any movement creating unilateral strain to the pelvis or requiring one leg to move differently than the other. 6

Uterine Ligament Strains

Over the 40 weeks (nine lunar months) of pregnancy the uterus blossoms from a plum sized pelvic organ to watermelon proportions. The fundus, or superior aspect, reaches xiphoid process level by term. It is suspended by the supportive structure of its ligaments. Formed of thickened external connective tissue of the uterus, these ligaments include: two broad ligaments extending laterally to attachments in the internal pelvic cavity walls at the ilea (these also support the fallopian tubes and ovaries); two round ligaments arising from the anterior, superior surface of the uterus and attaching in the connective tissue of the mons; the sacrouterine ligament continuing from the posterior uterus to attach on the posterior pelvic cavity wall at the anterior sacral surface.

As uterine growth inexorably stretches these ligaments, they typically refer pain beyond their attachment sites as follows:

  • Broad ligaments: low back, buttock and sciatic-like pain referral pattern, especially in the sixth month, and often disappearing in months seven or eight
  • Round ligaments: diagonal pain from the superior uterus to the groin; usually one sided, depending on fetal position; sometimes as extensively felt as the vulvar and upper thigh fascia
  • Sacrouterine ligament: achiness just lateral to or beneath the sacrum, especially in last three months.

Pain in one or both buttocks that radiates down the posterior leg is occasionally not referred from the broad ligament. Severe postural imbalance in the lumbar spine and pelvis or chronic piriformis tension may entrap and compress the sciatic nerve. Sciatic nerve pain is usually burning and may be accompanied by tingling, numbness, and weakness in the legs of only 1% of pregnant women. 7

Prenatal Massage Therapy for Lumbar and Pelvic Pain

Many touch therapies are effective for the pregnant pelvis. Promoting any one method or any procedural sequence as the maternity massage therapy would deprive women of the many benefits of the wide range of somatic practices available to the professional massage practitioner.

Therapists should focus on the muscles and joints listed above utilizing techniques that reduce muscle spasms and fibrosis, relieve myofascial shortening and pain, extinguish trigger points, reduce uterine ligament strain, and reeducate efficient structural integrity and body use. Beneficial methods include:

  • assisted resisted stretches, including proprioceptive neuromuscular facilitation and muscle energy techniques
  • craniosacral therapy
  • cross fiber friction
  • deep tissue massage, myofascial release, and structural balancing
  • passive movements, including joint mobilizations, rhythmic movements or trepidations, strain counterstrain or positional release, stretching, traction, and Trager  reflexive massage, including bindegewebsmassage, foot zone therapy, trigger point or neuromuscular massage, and Oriental methods somato-emotional integration Swedish massage

Educational activities also are effective interventions for reducing pain and decreasing stress on the weight bearing joints and other myofascial structures. 8 Correct and safe abdominal strengthening activities and body-use guidelines for walking, sitting, sleeping, carrying, and other daily activities will further reduce strain in the neck, back, and pelvis. 9 Introducing more efficient movement patterns enhances and reinforces the effectiveness of hands-on therapy, including those listed above for pain and spasm reduction.

Safety Guidelines in Prenatal Back and Pelvic Massage Therapy

Pain Level

It is essential to maintain pressure, speed, and intensity, regardless of method used, to never exceed a pregnant client’s experience of pleasure on the borderline of pain. This level of intensity allows for sufficient depth to accomplish most appropriate somatic practices’ therapeutic goals. Maintaining a pleasure/pain level also assures that neither the mother nor the fetus is stimulated to sympathetic arousal. Pain activates adrenal production of the hormones that elevate blood pressure, heartrate, and respiratory rate and which lower immune function and blood flow to the uterus. 10 Since these hormonal signals diffuse into fetal circulation through the placenta, the fetus is similarly negatively impacted. 11 Certain techniques require lighter pressure to be physiologically effective, and tissue health, injuries, and other safety considerations discussed later in this article often dictate more superficial touch.

Abdominal Pressure, Technique Modifications, and Positioning

While the techniques listed above are effective in relieving back and pelvic pain, insure that application of these techniques will neither increase intrauterine pressure, decrease blood flow to the uterus, or create localized, deep pressure into the abdomen.

Increased intrauterine pressure probably is not a significant safety concern in most normal, uncomplicated, low risk pregnancies. It is of particular relevance when there are abnormalities in placental attachment or function, or higher risk of such conditions; any uterine or cervical abnormalities; and any of many factors associated with concerns for fetal blood supply, such as high blood pressure, multiples, or intrauterine growth retardation. Women who have been diagnosed with these conditions often are uninformed about their impact in relationship to receiving massage therapy. Also, some of these problems go undetected until bleeding, cramping, or other overt signs of problems have occurred to warrant further diagnostics.

While the effect of deep abdominal massage techniques on pregnancy has never been specifically studied, increased intrauterine pressure and deep, pointed, or abrupt pressure into the abdomen may increase the risk of miscarriage, premature labor, or placental dysfunctions. 12 Thoroughly evaluate all massage therapy techniques contemplated for pregnant women to confirm that their performance will not directly or indirectly press into the abdomen. Many procedures, such as resisted assisted stretches and positional releases, are modifiable to avoid this safety concern. Further reduce the possibility of increasing intrauterine pressure by only massaging the pregnant abdomen at the skin and superficial fascia level. This precaution also applies to any techniques performed on the lateral abdomen, anterior of the quadratus lumborum. Light, full-handed pressure avoids any possibility of abdominal trauma that may provoke uterine contractions or injure the intestines.

Eliminate massage therapy in the prone position entirely after the first 13 weeks gestation, earlier if multiples or if the fetus is larger than normal gestational age. After the first three months, safe prone positioning for effective massage therapy is not possible, even with additional pillows, and/or tables and other equipment currently marketed for this purpose. Prone positioning with other equipment that doesn’t elevate intrauterine pressure often further strains the taxed uterine and lumbar ligaments, exacerbating the very causes of many women’s discomfort. The sacrouterine ligament is particularly vulnerable in prone position.

Supine positioning also involves safety considerations when working with pregnancy related sources of lumbar and pelvic pain. In this position, the weighty uterus compresses against the inferior vena cava. Extended compression will result in low maternal blood pressure and decreased circulation both to the mother and her fetus (supine hypotensive syndrome). 13 In second and third trimesters, mitigating measures for more extended supine positioning are prudent. Shift the uterus to the left side with pillow support under the right lumbar area (weeks 14-22), or, after 22 weeks, elevate the entire torso to a semireclined angle of at least 45 degrees. Use a densely cushioned therapy table, and provide sufficient supports for the lumbar area and the knees. When women are advised by their healthcare provider to never lie on their backs, always observe these restrictions.

When sufficiently supported with firm pillows, bolsters, and/or a Contoured bodyCushion, sidelying position is the safest, most posturally neutral, and most comfortable position for most women to receive prenatal massage therapy. Even in the sidelying position, however, pressure must be applied without rolling the woman onto her abdomen, and her top leg must be aligned horizontally with her hip. This is most important during deep work on the posterior structures when addressing back and pelvic pain.

Blood Clots

Avoiding deep, pointed, and/or ischemic compression to the pregnant abdomen also eliminates pressure into one of the most dangerous locations, the inguinal area. Blood clotting capacity escalates four to five times higher than non-pregnant levels during pregnancy. As fibrinolytic activity, the clot dissolving capacity of the blood, decreases dramatically, women are protected from potential hemorrhaging during childbirth; however, they also are more likely to develop blood clots (thrombi). 14

Clot formation is greatest in the veins where blood is most stagnant. The veins most likely to harbor clots during pregnancy are the iliac, femoral, and saphenous veins. 15 This is due to restriction of iliac and femoral venous return by the weight of the uterus on these vessels and to hormonal influences on vascular smooth muscle and on blood and fluid volumes. Given the likelihood of clots and their potential harm if freely circulating, do not press deeply into the abdomen, especially in the inguinal area. Additionally, use only soft, whole hand pressure throughout the medial surface of the legs where these veins traverse. Perform no tapotement nor deep, pointed, or stationary (ischemic) pressure, sufficiently sustained to restrict localized blood flow, regardless of the type of technique and its potential benefits.

Miscarriage and Prematurity

Miscarriage (spontaneous abortion) is a natural termination of pregnancy before the fetus has reached viability, most common in the first trimester. Preterm labor involves regular contractions that dilate the cervix after 20 weeks and before the end of 36 weeks gestation. Note that one of the most common symptoms of premature labor and miscarriage is low back/pelvic pain, referred from the contracting uterus; however, there are usually other identifying symptoms, such as bleeding or amniotic fluid leakage and abdominal cramping or regular uterine contractions. Remember that musculoskeletal back pain usually is relieved with a change in position or activity, while referred organic pain is not. Ask her physician to rule out miscarriage, preterm labor, or other possible causes of back pain, such as urinary tract infection, neurological dysfunctions, eclampsia, or prior, unresolved injuries. Take full prenatal and medical histories, and evaluate thoroughly at each massage therapy session.

Certain maternal conditions, high risk factors, and complications of pregnancy increase the risks of miscarriage and prematurity including:

  • previous miscarriage or preterm labor
  • altered nutrition leading to low maternal weight gain
  • smoking and other teratogenic agents such as radiation, alcohol, etc.
  • drug abuse, especially cocaine
  • emotional stress
  • heavy work load at home or on the job
  • decreased blood flow to the uterus caused by:placenta abrupto, placenta previa, diabetes, renal disease, cardiovascular disease, systemic lupus and other autoimmune factors, preeclampsia/eclampsia (GEPH), overdistension of the uterus in multiple gestations and polyhydramnios
  • abdominal trauma or surgery
  • premature rupture of membranes
  • diethylstilbestrol (DES) exposure in utero resulting in uterine abnormalities
  • incompetent cervix and other uterine anomalies
  • urinary tract or vaginal, uterine, or fetal infections
  • fever
  • maternal age over 36
  • chromosomal abnormalities 16

No one wants to have any doubt as to whether any massage therapy intervention was harmful nor have their protocols questioned. Some sobering facts of American maternity care are very relevant to massage therapy practitioners:  more than 75% of obstetricians and gynecologists are sued; more than one third of them are sued more than three times; and nurses and other perinatal healthcare providers are more and more frequently being included in these lawsuits. 17  Massage practitioners are wise to be aware of the litigious atmosphere in childbearing.

Some added precautions that could avoid erroneous, but costly, legal questions:

Do not touch the abdomen of a first trimester woman or of one whose risk of miscarriage or preterm labor is high. (See list above and sections later in this article on complications and high risk factors.) Always ask permission to gently touch her abdomen. Strictly adhere to midwives’ and physicians’ restrictions regarding abdominal massage. If not comprehensively trained in prenatal massage therapy, a further precaution worth considering is to not work with first trimester women or those at higher risk of pregnancy losses or prematurity.

Ligament laxity precautions

Symphysis pubis separation demands several special considerations in choosing and performing massage therapy. First: rolling over is painful with this condition, so minimize position changes. Second: firm, reliable bolsters and other supports are essential in all positions to prevent extended tugging on the joint. Finally, eliminate any techniques creating traction on the pelvic and hip joints or that compress the pelvis unilaterally.

All of a pregnant woman’s ligaments are easily overstretched due to the softening effect of relaxin. Overstretched ligaments result in joint instability and more pain. Minimally invested with elastic fibers, ligaments do not tighten after excessive lengthening. Modify assisted resisted stretches, positional release, Swedish gymnastic movements, range of motion, and other passive and active movements to avoid overstretching of joint structures.

Other complications and high risk pregnancies

In addition to miscarriage, premature labor, and placental dysfunctions, other physiologic complications to a normal gestation occur. These include: gestational diabetes and several types and severities of hypertensive disorders. When any complications arise, massage therapy is contraindicated until resolved or only with consultation with her healthcare provider. Cautious therapists will refer these women to more qualified prenatal massage therapists if not comprehensively educated in this work. If they do work with a complicated pregnancy, they will require written release from the woman’s healthcare provider and practice ultraconservatively.

In high risk pregnancies, either the mother or the fetus has a significantly increased chance of disability or death. Most of these conditions will not be negatively impacted by massage therapy; in fact, it may be invaluable in reducing the negative effects of increased anxiety and the bedrest frequently prescribed. With the further risk involved, however, thorough training and a written release from the woman’s healthcare provider are advisable.

Conclusion

The guidelines in this article are an introduction to effective, safe massage therapy for the pregnant pelvis. Pregnant women experience numerous other structural, physiological, and emotional changes and discomforts that respond well to specific, therapeutic techniques. Further study of the many other relevant intricacies of pregnant physiology and psychology and thorough, hands-on training and are highly recommended. 18

Carole Osborne-Sheets is the author of and Pre- and Perinatal Massage Therapy, and a contributor to the upcoming textbook Teaching Massage Therapy, as well as numerous other publications. She is the 2008 recipient of the AMTA Jerome Perlinski National Teacher of the Year Award. The work outlined in this article is adapted from portions of the author’s textbook Deep Tissue Sculpting.

For these and other books, click here.

For information about her certification program, Pre- and Perinatal Massage Therapy, and other hands-on workshops, click here.

Footnotes

  1. Unpublished survey of graduates of my former pregnancy training program,1994.
  2. Ostgaard, H.C., Andersson, G.B.J., et al.  Prevalence of back pain in pregnancy, Spine 17, 1: 53-55, January, 1992.
  3. Artal, R., Friedman, M.J., McNitt-Gray, J.L.  Orthopedic problems in pregnancy, The Physician and Sportsmedicine, 18: p. 93-105, 1990.
  4. Noble, Elizabeth, P.T.  Essential Exercises for the Childbearing Year.  Fourth edition, p. 20, 225.  Harwich, MA, New life Images, 1995.
  5. Ibid., p. 54.
  6. Ibid., p. 53.
  7. Ostgaard, p. 54.
  8. Osborne-Sheets, Carole.  Deep Tissue Sculpting: A Technical and Artistic Manual for Therapeutic Bodywork Practitioners.  Second Edition, p. 96-99  Body Therapy Associates, 2002.
  9. Noble, p. 81-146.
  10. Gorsuch, R. and Key, M.  Abnormalities of pregnancy as a function of anxiety and life stress, Psychosomatic Medicine 36:  p. 353, 1974.
  11. Catz, Charlotte.  Prevention of embryonic, fetal, and perinatal disease.  HEW, p. 123, 1976.
  12. Gilbert, Elizabeth Stepp and Harmon, Judith Smith.  Manual of High Risk Pregnancy and Delivery, p.265, 416.  St. Louis Missouri, Mosby – Yearbook, Inc., 1993.
  13. Ibid., p. 40.
  14. Ibid., p. 7.
  15. Alexander, Doug.  Deep vein thrombosis and massage therapy,  Massage Therapy Journal 32, 3: p. 56, 1993.
  16. Gilbert and Harmon, p. 265 and 416
  17. Ibid., p.160.
  18. Pre- and Perinatal Massage Therapy workshops taught by the author are offered nationwide. For more information contact us.
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Supporting Pregnancy with Massage Therapy

by Carole Osborne

Nurturing touch during pregnancy, labor, and the postpartum period is not a new concept. Cultural and anthropological studies reveal that massage and movement during the childbearing experience was and continues to be a prominent part of many cultures’ healthcare. (1) Studies indicate that most of the more peaceful cultures use touch prominently during pregnancy and early childhood. 2 Midwives, who for centuries have provided maternity care, have highly developed hands-on skills.

Current research on the benefits of touch is providing a contemporary basis for its reintroduction in many technological societies, including the United States. Scientists have found that rats restricted from cutaneous self stimulation had poorly developed placentas and 50% less mammary gland development. Their litters were often ill, stillborn, or died shortly after birth due to poor mothering skills. (3) Pregnant women massaged twice weekly for 5 weekly for 5 weeks experienced less anxiety, leg and back pain. They reported better sleep and improved moods, and their labors had fewer complications, including less premature births. (4) Studies show that when women received nurturing touch during later pregnancy they touch their babies more frequently and lovingly. (5) During labor the presence of a doula, a woman providing physical and emotional support, including extensive touching and massage, reduces the length of labor and number of complications, interventions, medications, and Cesareans. (6)

Why Pregnancy Massage Therapy?

Profound local and systemic changes in a woman’s physiology occur as a result of conception and the process of labor. Changes during pregnancy span the psychological, physiological, spiritual, and social realms, according to Carole Osborne, author of Pre- and Perinatal Massage Therapy and maternity massage therapy specialist since 1980. “Massage therapy can help a woman approach her due date with less anxiety, as well as less physical discomfort,” says Osborne.

A typical session performed by a therapist specializing in pre- and perinatal massage therapy, can address pregnancy’s various physical challenges: edema, postural changes, and pain in the lower back, pelvis, or hips. Swedish massage may facilitate gestation by supporting cardiac function, placental and mammary development, (7) and increasing cellular respiration. It also reduces edema and contributes to sympathetic nervous system sedation. (8) Deep tissue, trigger point, and both active and passive movements alleviate stress on weight-bearing joints and myofascial structures, especially the sacroiliac and lumbosacral joints, lumbar spine, hips, and pelvic musculature. (9) Structural balancing and postural reeducation reduce neck and back pain caused by improper posture and strain to the uterine ligaments. “Prenatal massage therapy also can facilitate ease of labor by preparing the muscles for release and support during childbirth,” according to Osborne.

“Beyond these physical effects, an effective prenatal massage therapy session provides emotional support,” says Osborne. In the safe care of a focused, nurturing therapist, many women unburden their worries, fears, and other anxieties about childbearing. She believes that bodywork helps the mother-to-be develop the sensory awareness necessary to birth more comfortably and actively. “Laboring women whose partners learned and provided basic massage strokes to their backs and legs had shorter, less complicated labors. (10) Imagine the benefits generated by the skilled hands of a trained touch specialist!”

The Postpartum Period

Beginning with the baby’s birth, a new mother must cope with more changes. She is typically only 10 to 12 pounds lighter, yet she is still maintaining her body with an anterior weight load posture. The massage practitioner can facilitate proprioceptive reprogramming to gently return the body to its pre-pregnancy state, to alleviate pain, and to bring about a renewed sense of body and self.

As a specialist in postpartum work, Osborne focuses on repositioning the pelvis and repatterning overall body use. Postpartum massage sessions can restore functional muscle use in the lumbar spine area, as well as strengthen and increase tonus in the abdominal musculature stretched and separated by pregnancy. Additionally, the overtaxed, hypotoned iliopsoas muscle functions can be improved. Upper back muscles which now support larger breasts and the carried infant’s weight need work to reduce strain, and to help maintain flexibility despite the physical stresses of infant feeding and care. For post-Cesarean mothers, specific therapeutic techniques also can reduce scar tissue formation (11) and facilitate the healing of the incision and related soft tissue areas, as well as support the somato-emotional integration of her childbearing experience.

Pre- & Perinatal Massage Therapy Education

To safely massage pregnant, laboring and postpartum women, Osborne feels that it is imperative that practitioners be knowledgeable about normal pre- and perinatal physiology, high risk factors, and complications of pregnancy. “Many of these conditions necessitate adaptations and consultation with physicians and/or midwives prior to sessions. Various techniques and methodologies must be modified or eliminated, depending on the individual and the trimester of pregnancy,” according to Osborne.

“Somatic practitioners will find reliable detailed, research based protocols and contraindications in Pre- and Perinatal Massage Therapy, and in my home study course based on that text,” says Osborne. For those seeking comprehensive hands-on training and certification as a maternity massage specialist, she recommends her 32 hour workshop.

“My Pre- & Perinatal Massage Therapy book and training programs developed from 27 years as a somatic practitioner and educator and 22 years of specialization in maternity and infant massage,” says Osborne. “Our students benefit from our continually expanding body of knowledge, research, clinical experience, and consultations with other perinatal health care providers.”

“Our instructors offer somatic therapists a safe and comprehensive approach to pregnancy, labor, and postpartum massage therapy. We also encourage an empathetic, non-judgmental attitude in supporting women’s ‘pregnant feelings’. These certification workshops include over 80 techniques specifically adapted for pre- and perinatal needs, and the practical marketing strategies, ethics, and skills to elicit collaboration with other perinatal specialists and to build a successful pre- and perinatal massage therapy practice.”

Application has been made to the Scottish Massage Therapy Association and the Guild of Complementary Practitioners for continuing professional development (CPD) points. Carole Osborne is approved by numerous American associations and agencies. She is approved by the National Certification Board for Therapeutic Massage and Bodywork as a continuing education provider (32 category A units: workshops include two ethics hours). Her workshops and staff are also approved by the Florida Board of Massage, California Board of Registered Nursing, and International Childbirth Educators Association; meet current American Massage Therapy Association continuing education standards; can be used for Associated Bodywork and Massage Professionals membership; and can be used for continuing education credit with Doulas of North America.

The Pre- & Perinatal Massage Therapy certification workshop is Carole’s expansion and refinement of the original Bodywork for the Childbearing Year® training which she co-created and taught from 1980-1996. Since 1980 she has trained over 4,000 massage and perinatal specialists throughout the United States, Canada, and Scotland. Her first textbook, Deep Tissue Sculpting, is an established professional text. To order a book or to learn more about the workshops Body Therapy Education at (858) 277-8827.

[minti_blockquote]Carole Osborne-Sheets is the author of and Pre- and Perinatal Massage Therapy, and a contributor to the upcoming textbook Teaching Massage Therapy, as well as numerous other publications. She is the 2008 recipient of the AMTA Jerome Perlinski National Teacher of the Year Award. The work outlined in this article is adapted from portions of the author’s textbook Deep Tissue Sculpting.

For these and other books, click here.

For information about her certification program, Pre- and Perinatal Massage Therapy, and other hands-on workshops, click here.

[/minti_blockquote]

Footnotes

  1. Goldsmith, Judith.  Childbirth Wisdom.  New York: Congdon and Weed, 1984.
  2. Prescott, James.  “The Origins of Love & Violence and the Developing Human Brain.”  Touch the Future, Long Beach, CA, Fall, 1995, pp. 9-15.
  3. Rosenblatt, J.S. and D.S. Lehrman.   Maternal behavior of the laboratory rat.  Maternal Behavior in Mammals, Wiley, New York, 1963, p. 14.
  4. Field, T.m M. Hernandez-Reif, S. Hart, H. Theakston, S. Schanberg, and C. Kuhn. Pregnant women benefit from massage therapy. J. Psychosomatic Obstetrics and Gynecology, 20(1), March, 1999, 31-8.
  5. Rubin, R. Maternal Touch. Nurs Outlook, 11/1963, ppp. 828-31
  6. Kennell, J.H., M.H. Klaus, S. McGrath, S. Robertson, C. Hinkley.   Continuous emotional support during labor in a US hospital.   J Am Med Assoc, 265, 1991, pp. 2197-2201
  7. Rosenblatt, J.S. and D.S. Lehrman.   Maternal behavior of the laboratory rat.  Maternal Behavior in Mammals, Wiley, New York, 1963, p. 14.
  8. Zanolla, R., Monzeglio, C., Balzarini, A., et al. “Evaluations of the results of three different methods of post-mastectomy lymphedema treatment.” J. Surg. Oncol. 26:1984, p. 210-13.
  9. Quebec Task Force on Spinal Disorders.  1987.  Scientific approach to the assessment and management of activity-related spinal disorders.  Spine, 12:, Supplement 1.
  10. Field, T., Hernandez-Reif, M., Taylor, S. , Quintino, O. Touch Research Institute, University of Miami School of Medicine and Iris Burman, Educating hands School of Massage Therapy. Journal of Psychosomatic Obstetrics and Gynecology, (in press 1998).
  11. Hufnagel, V., M.D. “Medical basis for using massage after surgery.” Massage Magazine #17, Dec-Jan/1988-89, p. 21.
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Maternity Massage: The Benefits of Prenatal and Perinatal Touch

Contribution to Midwife International by Carole Osborne, 2013

As midwives, it is important that we are able recommend supplementary care to make pregnancy and postpartum as comfortable as possible for the women we serve. In this piece, Carole Osborne, an internationally recognized maternity massage therapist and instructor, shares some of the benefits of prenatal and perinatal massage, and what makes this kind of care effective for mothers-to-be. She also gives direction for finding an effective maternity massage therapist for you to partner your midwifery care with.

Expecting a baby is usually joyful, but, as we know, it can also be stressful. A woman changes dramatically, and some of these changes are uncomfortable. Prenatal massage uses techniques designed specifically to make healthier moms and babies, despite pregnancy’s challenges, and to enhance its joys. Recent research is beginning to show that prenatal massage therapy may have these benefits:

  • Encourages relaxation
  • Helps alleviate muscle and joint pain
  • Improves breathing and digestion
  • Improves mom and baby’s physical and emotional health by reducing the negative impacts of stress on both
  • Helps a new mom feel more at home and in touch with herself and her baby
  • Contributes to easier, shorter labors
  • And it feels so good!

After giving birth, postpartum massage therapy may help abdominal recovery, reduce the strain of baby care on mom’s body, support satisfying breast feeding, and nurture mom and her family. Moms more quickly and fully touch their babies in loving, nurturing ways, after receiving massage, and that leads to a more peaceful world for us all.

In recent years, thousands of American massage therapists have trained to become pre- and perinatal massage therapy specialists. However, nurturing touch during pregnancy, labor, and the postpartum period is not a new concept. Midwives have been valued for centuries for their highly developed hands-on skills. Massage and movement during the childbearing experience was and continues to be a prominent part of many cultures’ maternity care. Most of the world’s more peaceful cultures use touch prominently during pregnancy and early childhood.

How Is Prenatal Massage Therapy Effective?

Changes during pregnancy span the psychological, physiological, spiritual and social realms. A typical session performed by a therapist specializing in pre- and perinatal massage therapy can address pregnancy’s various physical challenges: postural changes, pain in the lower back, pelvis hips, or ribs, and edema. The stress-reducing effect of massage not only may relax mom, but it may also improve uterine blood supply and fetal and maternal outcomes. Prenatal massage therapy also may facilitate ease of labor by preparing selected musculature and joints to either soften or support during childbirth.

Beyond these physical effects, an effective pregnancy massage therapy session provides emotional support. In the safe care of a focused, nurturing therapist, many women unburden their fears and other childbearing worries. Therapeutic massage and bodywork may help the mother-to-be develop the sensory awareness necessary to birth more comfortably and actively. If laboring women whose partners learned and provided basic massage strokes to their backs and legs had shorter, less complicated labors, imagine the benefits that might be generated by the skilled hands and compassionate heart of a trained touch specialist!

The Postpartum Period

Beginning with the baby’s birth, a new mother must cope with many changes. She weighs less, yet still habitually holds her body for an anterior weight load posture. A postpartum massage therapy session may facilitate a gentle return to the body’s pre-pregnancy functioning, alleviate pain and to bring about a renewed sense of body and self. Upper back muscles, which now support larger breasts and the carried infant’s weight, appreciate massage to reduce strain and to help maintain flexibility despite the physical exertion and repetitiveness of infant feeding and care.

Regardless of methodology, an hour focused on her own relaxation and comfort works wonders for a new mom’s mood. Another empathetic ear hearing her birth story may further resolve any residual emotional conflicts that can emerge during labor and early mothering. Several recent studies suggest that massage therapy may help prevent or reduce prenatal and postpartum depression. For post-cesarean mothers, specific therapeutic techniques also may reduce scar tissue formation and facilitate the healing of the incision and related soft tissue areas, as well as support the integration of her childbearing experience.

Identifying Qualified Pre- and Perinatal Massage Therapists

Parents and childbirth professionals will want both a safe and effective massage therapist. Seek out a maternity massage therapy specialist, not just a general massage therapist. A certified specialist is knowledgeable and also skillful in adapting her techniques to safely meet women’s needs. She will approach her pre- and perinatal clients with deep respect for the normalcy of pregnancy, its joys and its many challenges.

When identifying maternity massage therapists, look for those who observe detailed, research-based protocols and contra indications. A comprehensive hands-on training in prenatal and perinatal massage therapy requires at least 32 hours; ideally it also includes a performance evaluation to certify the therapists’ proficiency. Maternity specialists have the knowledge and skills to collaborate well with perinatal health care providers to offer effective and empathetic touch to moms. After seeing their greater comfort, midwives and other providers might even find themselves scheduling their own hour of timeless, nurturing touch!

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How to Network with Fertility Experts in the Medical Realm

Experienced perinatal massage therapists develop professional relationships with fertility treatment experts primarily in three methods: their patients, their staff members and through educational activities.

The easiest route to doctors, licensed acupuncturists, psychotherapists and other providers is through their patients. If you have a client undergoing fertility treatments, ask her to share the benefits she feels from your work with her doctor.

Read entire article

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Pregnancy Massage

The more we start to understand about the benefits of massage therapy, the more opportunity opens up for massage therapy professionals—in a wide variety of environments. When thinking about where you’d like to practice, having as much information about the options available can help you choose a work environment, or environments, that fit both your personal and professional goals. In the following, you’ll find information ranging from what you can expect when working with pregnant women to the demands of working with women in labor to how you can market maternity massage. In this snapshot, you’ll get an inside look at working with this demographic so you can make informed decisions about where you want to take your massage therapy career.

Read entire article

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Maternity Massage Therapy – For Pregnant, Laboring and Postpartum Women

Maternity-massage therapy is one of the most personally rewarding and professionally satisfying massage therapy specializations. Maternity massage addresses the many needs of women throughout an entire childbearing cycle, rather than just during pregnancy. If you are considering entering the world of bellies roiling with life, labor’s powerful groans and the sweetness of a mom embracing her newborn, you will need a sense of what this really entails.

Read entire article (PDF)

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Ah, What Relief! Deep Tissue Sculpting for Lumbar Pain

By Carole Osborne

Nagging, like an animal gnawing; sharp, like a piercing knife; throbbing, like a smashed fingertip. These are all samples of how low-back pain can feel to suffering clients. The common complaint of lumbar pain is often the result of myofascial tension, distortion, and dysfunction. Therapists need a clear understanding of, and a straightforward approach to, addressing lumbar pain. By using the gentle, but penetrating approach of deep-tissue sculpting, your ability to observe structural organization and to direct your clients toward appropriate activities and self-care will improve

The Hows and Whys of Lumbar Pain

Typically, clients complaining of low-back pain will present with lumbosacral misalignment, characterized by excessive (lordosis) or flattened lumbar curvature, anterior or posterior pelvic tipping, and/or rotations and uneven iliac crest heights. Observe your clients’ personal tension patterns. Their spinal extensor muscles will usually appear as tight, wiry ridges next to the spine. The lumbodorsal fascia will feel bound to neighboring tissue layers. Your goal will be to relieve the lumbar spine compression that is the result of these chronically shortened myofascia.

Often tight hamstrings and quadriceps, as well as hypotoned or hypertoned abdominals and iliopsoas muscles, contribute to low-back tension. Your clients will often appear to be so compacted at the lumbar level that their bodies’ weight will not settle through the pelvis into the legs. It is almost as though the legs are not fully functioning as connectors to the ground; they seem, instead, to be the legs on a stick figure. They need posterior length, anterior to posterior balance, and continuity in function between their torso and lower extremities. This should be the other goal of your session together.

Inefficient breathing patterns also exacerbate low-back pain. Shallow chest breathing and hyperventilation limit the amount and quality of spinal movement. Without the rhythmic waves involved in deep, abdominal expansion during full inhalation and exhalation, the spine can become rigid and inflexible. Because the crural attachments are intimately woven beside the psoas at the anterior lumbar spine, a tense diaphragm can transfer restriction and pain throughout the abdominal and lumbar regions.

Conversely, lower torso tension can significantly limit breathing. Abdominal tension can prevent full excursion of the diaphragm by minimizing room for the necessary expansion of the rib cage and displacement of the abdominal organs during inhalation. Other posterior muscles, including serratus posterior inferior and superior and levator costarum, influence respiratory depth and ease. When these smaller, more intrinsic muscles are restricted, the rib cage cannot expand to achieve its maximum posterior and lateral excursion.

Of course, you will also need to consider any underlying conditions, such as muscular strains and sprains, damaged or stressed discs, arthritis, or other inflammatory conditions 1 that may be present. And pregnant and postpartum women’s backs are a story all their own. 2 As you get your mind around an individual client’s condition, remember these contributing factors and adapt your technique accordingly when working with these clients.

Chronic Myofascial Restriction

So, how will you actually touch this client’s needy body? A full-body or deep, localized Swedish massage? Passive and active resisted stretching? Extinguishing relevant trigger points? All these therapeutic approaches would possibly be effective, but for our purposes here, we are going to zero in on the use of focused compression, sustained sufficiently to soften and change both muscular and connective tissue of relevant structures. I call my style of this type of bodywork deep-tissue sculpting.

Sculpting is a form of deep-tissue massage characterized by firm, constant compressions and strokes applied parallel to the muscle fibers. Like other myofascial bodywork methods, the techniques are intended to affect the deeper musculoskeletal structures, as well as the more superficial structures. In order to reach these deeper layers, you will use fingertips, knuckles, elbows, forearms, and heels of the hand, or any bony body part as tools. Pressure is gradually applied to a tight area until a resistance is met.

You will maintain constant pressure while the tissue relaxes and until release is completed, or until you accept that no change is forthcoming. Any pain experienced by the client should not exceed pleasure, hovering at the borderline of pain. Don’t use lubricants, so that the work can proceed slowly, allowing fascial softening and muscular lengthening. Generally, a minimum of 30–60 seconds is needed to elicit long-lasting myofascial change. This more extended time commitment also helps the client assimilate the deeper pressures, as well as the intensity of physical sensations and emotions that can occur.

When doing deep-tissue sculpting, imagine yourself as a sculpting artist. Figuratively carve away that which is not the essence of the human body, much as a sculptor would remove from a lump of clay or slab of stone that which is not the essence of the object she is creating. Hold a mental picture of the muscle or fascial sheath sculpted as it appears in the anatomy books. Imagine the myofascia as free of bunched, constricted, or disorganized areas, and intend your hands to create that. More specifically, incorporate imagery to guide your sculpting.

Now let’s get into our lumbar pain session work and see what it might look like.

Opening a Session

As always, open your session with appropriate contact and evaluation techniques. Observe and evaluate your client to guide you in determining the appropriateness and efficacy of each of the techniques: feel free to omit some and emphasize others.

You can direct your work by holding a mental image as a guiding thought while working. For a low-back pain client, imagine elongating the client’s back and connecting the torso and legs. Create a mental picture of lengthened spinal extensors and continuity between the client’s hamstrings and pelvic myofascia, as well as between the abdominals and anterior thigh. Imagine lengthening fluidly through the quadratus lumborum and iliopsoas myofascial connections between the pelvis and the legs. You might also engage your client to imagine this elongation and connection as you work together.

Throughout the session, augment your sculpting with sequences from other modalities and include movement or stretches that further your intention and provide transitions between sculpting that are uniquely created for your individual client. Watch your use of lubricants and sequence of procedures so that you can sculpt without slipping; this will help ensure sufficient myofascial traction to get a “fuller” connection with these tissues. There are other soft-tissue therapies you might integrate or blend together to further enhance this sculpting work. Remember to bring closure to your work with techniques that integrate the remainder of your client’s body.

Deep-Tissue Procedures

Position the client prone or sidelying for the first four procedures. Use your elbow, forearm, fist, knuckle, or finger, depending on your size and your client’s and the depth of structure to be sculpted. Dashed lines on photos represent areas to sculpt; solid arrows denote vector of pressure to apply.

1. Lengthening the Back (image 1) intention and imagerylowerback-image1

To elongate and relax the muscles and fascia attaching to and paralleling the spine, primarily trapezius, thorocolumbar aponeurosis, rhomboids, erector spinae, and posterior fascial sheaths.

PROCEDURE

From a position in front of the client’s head, begin stroking/compressing along the tissue lateral to the spine. Continue from near the C–7 area to the sacral base, changing tools as the muscles narrow above and over the sacrum.

PRECAUTIONS

  • Do not stroke directly over spinous processes
  • In the lumbar area, be sure to direct pressure more toward the sacrum than anterior, to avoid excessively curving the lower back.
  • If lumbar lordosis is extreme, support under the abdomen. Or, do this and all other prone procedures with the client in a sidelying position.

lowerback-image2-3HINTS

Work both simultaneously, or left then right sides of the back. Do not force an unbroken stroke if the tissue is not elongating. A series of compressions is equally as effective and a combination of stroking and compressions will more likely be the pattern of release. Change tools as needed to accommodate body position and to avoid excessive leaning over the table.

2. Defining the superior and inferior iliac crest (images 2 and 3) intention and imagery

To create skeletal awareness of the pelvis at the iliac crest by releasing tension in the attaching muscles and fascial sheaths, as well as elongating the back.

PROCEDURE

Compress superior to the iliac crest, beginning near the lumbosacral joint, and progress laterally, making a series of compressions. If the tissue yields sufficiently, melt through and release the thorocolumbar aponeurosis, the erector spinae, the quadratus lumborum, and the transverse and oblique abdominals. Next, compress inferior to the iliac crest, beginning near the lateral side of the posterior iliac spine and progress laterally making a series of compressions. If the tissue yields sufficiently, melt through and release the attachments of the gluteus medius. Do this on one side of the body, then the other.

3. Defining the Sacrum and releasing the gluteal myofascia (image 4) intentions and lowerback-image4-5imagery

To create skeletal awareness of the sacrum, and elongation of the gluteus maximus myofascia using an image of connecting torso to legs.

PROCEDURES

First, compress along the lateral sacral border, releasing tension in the gluteus maximus attachments to make contact with the bone. Make a series of compressions, moving inferior along the sacrum, to near the coccyx. Then compress and/or stroke the gluteus maximus from origin toward the insertion, elongating and melting the muscle and fascia. Do this on one side of the body, then the other.

PRECAUTIONS

  • The sciatic nerve is embedded beneath the gluteus maximus and may be sensitive to deep compressions. Change position, direction, or depth of pressure if the client experiences an electrical, burning, numbing, or painful sensation down the posterior leg.
  • Be especially sensitive near the coccyx to slowly melt to depth, particularly if there has been any previous coccygeal injury.

4. Lengthening the hamstring group myofascia  (image 5) intentions and imagery

To elongate the hamstring muscle group and investing fascia, as well as realign the ischial tuberosities from any anterior displacement.

PROCEDURES

Begin with a compression on the ischial tuberosity. Continue with a series of compressions or a slow melting stroke down the hamstring group to just above the knee, where the muscles separate to attach laterally. Finish with smaller tools sculpting the tibial and fibular attachments. If you prefer, work from the knee toward the ischial tuberosity. Do this on one side of the body, then the other.

PRECAUTIONS

Remember to avoid deep pressure on varicose veins and redirect sculpting to move in a distal to proximal direction. Eliminate sculpting in this area entirely if severe bulging or ropy varicose veins are present. Avoid direct pressure in the popliteal area of the posterior knee.

5. Lengthening of the quadriceps group myofascia (image 6) intentions and imagery

To elongate the quadriceps group and its investing fascia, release the anterior superior iliac spine (ASIS) from any posterior displacement and connect the torso and legs.

lowerback-image4-5PROCEDURES

Position the client supine. Begin compressing the rectus femoris origin just below the ASIS. Follow any elongating release distally, or make a series of compressions to just proximal of the patella. Repeat on the vastus medialis and lateralis. Use a smaller tool to sculpt the quadriceps attachments at each side of the patella, then similarly sculpt the other leg. If you prefer, work from the knee toward the pelvis.

 

 

 

PRECAUTIONS

  • Avoid deep pressure on varicose veins and redirect sculpting to move in a distal to proximal direction.
  • Eliminate sculpting in this area entirely if severe, bulging, or ropy varicose veins are present.

6. Abdominals Release (image 7) intention and imagery

To reduce tension in the rectus, oblique, and transverse abdominus muscles and shorten their interwoven fascia.

PROCEDURES

Position the client supine. Use the heel of your hand to compress gently into the abdominal muscles, especially along each edge of the rectus. Make a series of compressions to release the entire abdomen. Carefully compress from near the sternal xyphoid process and along the inferior edge of the rib cage, releasing the abdominals, especially the rectus and oblique abdominals. Similarly sculpt along the other side of the distal rib cage.

PRECAUTIONS

  • Melt slowly to avoid painful pressure on abdominal organs.
  • Do not use this procedure on pregnant or menstruating women, nor with anyone experiencing undiagnosed abdominal pain. 3
  • Avoid painful pressure on the floating 11th rib by ending the rib cage compressions at the end of the costal cartilages.

7. Anterior flat of the ilium (image 8) intentions and imagerylowerback-image8

To create skeletal awareness of the pelvis and iliopsoas myofascia and deep release and receptivity into the abdominal muscles.

PROCEDURES

Position the client supine. Begin near the anterior superior iliac spine, compressing medial and toward the pubic ramus. Melt slowly and gently into the abdominals then iliacus, proceeding as the myofascia yields as if “skiing” down the slope of the iliac bowl. If release allows you to contact the psoas muscle, continue in an inferior direction releasing any stringiness, bunching, or tenderness there. Similarly sculpt the other side. This procedure may also be done with the client sidelying.

PRECAUTIONS

  • By entering at the ASIS, keeping the palmar side of your fingers against the flat of the ilium, and reducing pressure if painful, you will avoid any pointed or excessive pressure on the abdominal organs.
  • Be especially sensitive to wait for the client’s release and to avoid working beyond his experience of the “pleasure/pain borderline.”
  • Do not apply direct pressure in an inferior direction on the inguinal ligament as it may be weakened and would then encourage herniation.
  • Do not use this procedure on pregnant or menstruating women, or with any client experiencing undiagnosed abdominal pain. Delay application with postpartum women for 8–10 weeks after childbirth. 4

8. Quadratus Lumborum Stretch (image 9) intention and imagery

To release the quadratus, imagining more space between the ribs and iliac crest, and lengthen the back.

lowerback-image9

PROCEDURE

Do this final procedure with the client sidelying, first on one then the other side. Use the forearm or fingertips to compress in a medial and inferior direction on the quadratus.

 

HINTS

If your forearm is too wide or you can’t locate the muscle belly, work using your fingertips.

Strokes to Emphasize for Individual Imbalances

Those clients with excessive lumbar curvatures (lumbar lordosis) benefit most from sculpting of the posterior fascia, erector spinae, quadriceps group, and the muscles attaching at the sacrum, iliac crest, and anterior surface of the ilium. When your client’s alignment reveals a flattened lumbar curve, emphasize sculpting the gluteals and hamstring groups. To change pelvic alignment sufficiently to reduce muscle strain and spasm, encourage iliopsoas toning and stretching. Relax the quadratus lumborum on the higher side to balance uneven iliac crest heights. To release scoliosis, sculpt thoroughly and in detail on the erector spinae, especially on the sides inside the S-curve. The quadratus lumborum also will benefit from careful sculpting. 5

Supportive Activities and Stretching

In addition to your table work, your client may need guidance in daily exercise, activities, and other ways to reinforce the changes experienced. If there’s some residual pain, show him how to find a comfortable resting position. 6 As pain subsides, encourage him to improve balance and strength in the iliopsoas, abdominals, erector spinae, quadriceps, and hamstring muscles. Practice pelvic tilting in lying, standing, and on all-fours positions. This uses the iliopsoas for pelvic positioning on the frontal plane and strengthens this muscle unit. Knee-to-chest stretches elongate lumbar and the hamstring myofascia. 7 Another option is to actively stretch the quads and hamstring muscle groups after 2–5 seconds of muscle use against resistance. 8 Healthy backs can benefit from more strenuous exercise and stretching, including yoga and movements that twist, rotate, flex, and extend the spine. 9

You may need to evaluate the daily activities of low-back pain clients, as well as their environments and habits, to eliminate other factors contributing to their pain. 10 While lumbar pain is a physical experience, most somatic psychologies suggest that tightened pelvic muscles reflect a need for control. These areas can harbor fear—of life, vitality, and sexuality. Nerves emerging from the lumbar spine activate the sexual and eliminative functions, as well as the legs and feet. Rigidity and imbalance here can block the pelvis from free movement, thereby inhibiting fluid walking, dancing, and sexual expression. Since lumbar alignment is a function of balance between the anterior and posterior musculature, consider some abdominal correlations too. Issues of nourishment and assimilation of emotions, as well as food, can settle here. Thus, lumbar tension might more fully resolve if a client is willing to explore his unexpressed emotions concerning nurturance and sexuality. 11

Conclusion

Low-back pain ranks second to acute respiratory illness as a cause of time lost from work. 12 Some surveys estimate that 80 percent of all people will be affected by back pain some time during their lives, and it appears that massage therapy can help them. 13, 14, 15 Your next week’s client list will likely include several low-back pain sufferers. With this overview of the condition in mind and this hour-long protocol of deep-tissue techniques in your hands, you’ll be ready to reduce their discomfort in a penetrating, yet sensitive way.

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Carole Osborne-Sheets is the author of and Pre- and Perinatal Massage Therapy, and a contributor to the upcoming textbook Teaching Massage Therapy, as well as numerous other publications. She is the 2008 recipient of the AMTA Jerome Perlinski National Teacher of the Year Award. The work outlined in this article is adapted from portions of the author’s textbook Deep Tissue Sculpting.

For these and other books, click here.

For information about her certification program, Pre- and Perinatal Massage Therapy, and other hands-on workshops, click here.

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Footnotes

  1. Carole Osborne-Sheets, Deep Tissue Sculpting, 2nd ed. (San Diego: Body Therapy Associates, 2002), 39–44.
  2.  Carole Osborne-Sheets, Pre- and Perinatal Massage Therapy (San Diego: Body Therapy Associates, 1998), 12–16.
  3.  Ibid., 36–38.
  4.  Ibid., 135.
  5.  For another insightful look at myofascial lengthening in the low-back area, see Doug Alexander, “Lengthening Stereotypes,” Massage Therapy Journal 38, no. 2 (Summer 1999): 40–54.
  6.  Maggie Leavin, Maggie’s Back Book: Healing the Hurt in Your Lower Back, (Boston: Houghton Mifflin Co., 1976).
  7.  For a Feldenkrais approach to low-back care, see David Zemach-Bersin, Kaethe Zemach-Bersin, and Mark Reese, Relaxercise, (New York: HarperCollins Publishers, 1990).
  8.  Aaron L.Mattes and Suzanne T. Mattes, Active Isolated Stretching: The Mattes Method (Aaron Mattes Therapy, 2006).
  9. Oscar Ichazo, Psychocalisthenics: Master Exercise (Sequoia Press, 1993).
  10. Leavin, ibid.
  11. Kenneth Dychtwald, Body/Mind (New York: G.P. Putnam’s Sons, 1986), especially Chapter 5.
  12. Postgraduate Medicine Journal, 1981.
  13. C.M. Godfrey, P.P. Morgan, and J. Schatzker, “A randomized trial of manipulation for low-back pain in a medical setting,” Spine 9 (1984): 301–4.
  14. Tiffany Field, Iris Burman, et al., International Journal of Neuroscience 106 (2001): 131–45.
  15. D. C. Cherkin, D. Eisenber, K.J. Sherman, W. Barlow, T.J. Kaptchuck, J. Street, and R.A. Deyo, “Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low-back pain,”Archives of Internal Medicine 161 (2001): 1081–8.
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Health Maintenance – Preventive Care for Hands and Bodies

By Carole Osborne-Sheets
Massage & Bodywork, July/August 2008, p 74

As a continuing education teacher working with practitioners from many different schools, I’ve commiserated with the pain and frustration of poor body and hand care. Carpal tunnel, tendonitis, and thoracic outlet syndrome are far too common in our profession. Chronic back, neck, and shoulder pain shorten many a lucrative career. Most of this is preventable, and here’s how.

My 33-year career in bodywork has offered me many lessons. One I learned quickly, in fact in my first two years, was to attend to my own body use and maintenance. When a vague thumb and shoulder achiness began to temper my beginner’s zeal, I discovered how to prevent it from becoming chronically painful. As I learned more efficient use of my body weight with balanced alignment, those problems diminished. After that incident, body use and care became an integral part of my daily routine and of every instructional program I have developed subsequently. Now I celebrate both my own successful and relatively pain-free career, as well as those of the practitioners I have trained.

Care, development, and protection of your hands and body are crucial for effectiveness and career longevity, no matter which bodywork or massage specialty you practice. Because of the stress of sustained pressures, practitioners of deep tissue, neuromuscular, structural integration, and other body therapies need to be especially mindful of:

  • Appropriate choice and variety of tools utilized (i.e., elbow, fingertips, knuckles, etc.)
  • Balanced alignment of the entire body and appropriate weight shifts to apply pressure
  • Extra bracing and specific alignment of the entire pectoral girdle, including the elbow, finger joints, scapulo-thoracic, shoulder, and wrist
  • Core stability and hand flexibility, dexterity, and strength
  • Regular cleansing and maintenance

Body Alignment and Weight Shift

Table Size and Height

Endurance, focus, receptivity, relaxation, and strength in the hands result from effective use of the entire body. Proper table width and height are the first requirements to achieve efficient, stress-free body alignment. A 27″–30″ wide table will usually allow the client adequate room, while enabling most practitioners to shift their weight over the table without excessive leaning and strain to their backs. Choose a narrower table if you are short; however, you may then need side extensions or some other measure to accommodate larger clients’ arms.

Most practitioners work best with their table height adjusted so that, when standing erect and arms hanging loosely at the side, the tabletop touches between knuckles and wrist. This height encourages and allows for use of the lower body for pressure and weight shifting. It prevents the need for extreme knee bending or for muscling technique from the upper body. Of course, modify this rule for your body shape. When working with side-lying clients, the higher end of this range allows for the more horizontal weight shift involved. When working with heavier clients or using a contoured body cushion or other client positioners, adapt by lowering table settings.

Stance and Weight Shift

healthmain-image1-3Refer to image 1 as you apply the following guidelines. When standing beside a massage table, plant your feet firmly on the floor. Spacing your feet shoulders’ width apart and one foot ahead of the other by one to three foot lengths is usually best. Flex your knees. Don’t tire yourself with too deep a stance, but avoid limiting your weight shift and maneuverability with too shallow a stance. You can shift your body weight directly into your working tool if your torso is facing toward the point where you intend to apply pressure. The more direct the vector of pressure applied, the less energy required to achieve effective depth.

Think of your body’s center of gravity (in the lower abdomen) as a flashlight aimed as directly as possible at the structure you want to touch. Aligning your spine, with no excessive curvatures, rotations, or twists (especially of the lumbar and cervical areas), is crucial in minimizing stress and avoiding injury. Lengthen your entire spine, but maintain gentle curvatures. Lengthen your lower spine by imagining a weight attached to your coccyx, drawing it toward the ground. To lengthen the upper spine, imagine a hook at the crown of your head attached to the sky.

To get lower, bend at your hip joints or knees. Do not from your waist, which can strain your lower back. Notice and correct any collapse or side-bending of your head or torso. Look downward when you need to locate structures and monitor client reaction, then realign your head on your spine, reestablishing a gentle cervical curvature with your chin gently tucked in. In summary, weight shifting from the lower body is more efficient and comfortable (image 1). Upper body “muscling” of technique usually creates pectoral girdle and spinal collapse and pain (image 2).

Avoid side-bending head and upper body when clients are side-lying (image 3).

With balanced alignment, and the table at the proper width and height, you are ready to perform your technique, whether it will be a compression into a trigger point, effleurage, kneading, a passive joint movement, or a slow, melting deep-tissue sculpt. Gather your weight into your rear leg, emptying your front leg of weight, but allowing it to remain relaxed, resting on the floor. Initiate and maintain momentum by pushing into the ground with the rear leg, but do not lock that knee in doing so. Direct your weight into your working tool, and avoid loading your front leg, which should remain empty, relaxed, and free to step if needed. Increase pressure by pressing into the ground and lean more heavily onto your tool; lighten it by shifting subtly back into the rear leg. Release your pressure by regathering your weight into the rear leg. With each technique applied, push from the back leg into the area being compressed or stroked. Accomplish movements (such as many traction stretches) away from the client’s body and return effleurage by similarly shifting weight from front foot to back foot. Start traction moves with weight forward, then shift gradually to the rear leg (image 4).

For procedures (such as petrissage or some lomi lomi strokes) that require you to squarely face the side of the table, a “horse riding” stance is more efficient. In this stance, your feet are parallel to each other, at least as far apart as your shoulders’ width, and your knees are flexed. Weight shifting between the feet should power your arms for techniques. Allow your torso to rotate around your lower abdomen much like a washing machine agitator moves.

healthmain-image4-6Seated Work

When working in a seated position, plant your feet firmly on the floor. In this position, the actual weight shifts must result from your ischial tuberosities pressing into the stool or chair, thereby, functioning as the feet do when standing. Of course, always maintain spinal alignment with the head erect, and relax your shoulder girdle. Effective seated body use involves relaxed, erect alignment (image 5). Sustained side-bending and hunched shoulders can create both practitioner and client pain (image 6).

Upper Body Alignment

Relax all unnecessary contraction of the pectoral girdle muscles so that your shoulders remain down, balanced horizontally on the torso. Avoid hunching and anterior rounding of the shoulders when applying techniques. Pay particular attention to releasing excess tension in your levator scapulae, rhomboids, supraspinatus, and trapezius. Your biceps, deltoids, latissimus dorsi, pectoralis major, trapezius, and triceps will not be overused if you use your body weight efficiently to create pressure, rather than pushing from your arms. To stabilize your shoulder and scapulothoracic joints as you shift your weight into your client’s body, balance the functions of the serratus anterior/rhomboids and the latissimus dorsi/upper trapezius, along with the humeral stabilizers (i.e., infraspinatus, subscapularis, and teres minor).

When the forearm or elbow is used, only the contraction of the elbow flexors is necessary; keep the forearm, hand, and wrist relaxed. Stabilize the shoulder and scapulothoracic joints in an open, balanced position, avoiding excessive humeral adduction or abduction, and let your shifted body weight be the source of pressure. Apply no pressure from the head, other hand, or the shoulder and back muscles. This will avoid strain to your upper extremity. You will also prevent possible injuries, such as bursitis, neuritis, rotator cuff syndrome, and tennis elbow. Relaxed arm, hand, and shoulder positions deliver deep, sensitive pressure (image 7).

Joint Protection

healthmain-image7-8Your hands need to perceive the needs of the tissue beneath. They perform fine, delicate movements as they direct energy and apply appropriate technique. They sustain the weight of your body as you apply compressions, kneading procedures, or stroking. They are the most important tools of your trade. You must protect the integrity of your elbows, fingers, and wrists. Whatever technique you apply, perform it with as much open, balanced alignment of these joints as possible. If you repeatedly hyperextend your wrist joint during deep palmar and hypothenar strokes, carpal tunnel syndrome, ligament strain in the wrist, and/or tendonitis can result.

Avoid wrist hyperextension and overuse of the heel of the hand by effleuraging with soft-fisted knuckles whenever possible (image 8).

Excessive pressure on your fingertips, particularly on the thumbs, can hyperextend or hyperflex the metacarpal-phalangeal joint. The resulting ligament strain and stretching can cause instability, pain, and swelling in the affected joints. Avoid these problems by bracing or supporting your fingers and hands to create additional protection for the joints sustaining the greatest pressures. For example, the fisted hand can brace behind your thumb, or your other hand can act as a splint for the phalangeal joints when fingertip pressure is required.

Use one hand to apply pressure while the other stabilizes the working fingers (image 9).

Exclusive and/or improper use of any tool—but especially the fingertips, heel of the hand, or thumbs—can result in joint-structure damage. Reserve these tools for small areas, specific, definition-type work, and thinner, less-tense muscles. By regularly using alternative tools such as your elbows, forearms, and knuckles, you can sensitize them to nearly as fine a receptivity as your fingertips. Vary which tool you use throughout each session. Since the structure of the elbow and fisted hand are more capable of sustaining deep pressure without threat to joint integrity, use these tools for deepest pressures whenever possible. Carpal tunnel syndrome, irritation and inflammation of the joint capsule, osteoarthritis, and strained ligaments are all probable results of using one tool more than others or attempting to release large masses of muscle with smaller tools such as thumbs or fingertips. Fists are effective tools for denser muscles and when needing deeper pressures (image 10).

Developing Hand Strength

healthmain-image9-10Work with both left and right sides of your body so that both hands and arms are equally strong and agile. You can increase control, dexterity, and strength in your hands while enjoying the products and pleasures of activities like playing piano, guitar, or rhythm instruments; typing; or weed pulling. Other more structured exercises include:

  • Fisting your hand, then rhythmically squeezing it tighter, moving from little finger to ring finger, and so on through the thumb, and repeating this sequence increasingly faster and for more repetitions as the hand develops.
  • Placing a poker chip between two fingers and “walking” it to the next two fingers and back without using the other hand.
  • Playing tossing games with first one poker chip, then as many as three, developing both one- and two-handed tossing and catching patterns.
  • Pushing the fingertips of one hand against those of the other, either simultaneously, or from little finger through thumb in a rhythmic sequence.
  • Rhythmically rolling three marbles or large steel ball bearings in your palm.
  • Squeezing a firm ball, such as a tennis ball, or Power Putty, a product available in many athletic stores.
  • Touching each fingertip to thumb-tip in a smooth, increasingly brisk rhythm.

healthmain-image11Core Body Stability—Pectoral Girdle

Proper alignment and balance of your pectoral girdle as it sustains much of your body weight is difficult without adequate upper body strength. Maintain a regular program of exercise, weight training, or other activities that target strength and flexibility in these muscles: biceps, latissimus dorsi, rhomboids, shoulder joint stabilizers, trapezius, triceps, and, most importantly, the serratus anterior. The serratus provide critical downward rotation of the scapula, stabilizing it and the rest of your shoulder girdle against the posterior driving force you create when leaning your body weight to massage.

Most practitioners can easily incorporate daily push-ups to develop a foundation of pectoral girdle strength. If you cannot do a full push-up, then work toward that goal with progressively more strenuous push-up variations. Start by doing push-aways (image 11):

  1. Stand one to two feet from a wall or other sturdy, flat vertical surface.
  2. Place your palms or your fisted knuckles against the wall and lean onto them while sustaining a rigid position.
  3. Drop toward and then push your upper body away from the wall, maintaining alignment of your scapula against your back.
  4. Repeat for 12 repetitions. Rest and repeat 12 times. After several weeks of regular exercise, intensify the effort required by standing further and further from the wall, thereby taking more and more of your body weight onto your arms.
  5. Progress to the floor push-ups when you feel ready. Initially, hold your weight on your knees and hands, moving to standard military push-ups on toes and hands when your strength is sufficiently developed.

Pectoral girdle strengthening begins with push-aways and progresses to full push-ups.

Increasing Body Energy: A Tai Chi Exercise

Protect and strengthen your hands by increasing overall body energy and by learning to direct that energy through your hands. Traditional Asian disciplines such as tai chi chuan and qigong are notable for their effect in developing the body’s vital energy (chi). If experienced teachers in these arts are unavailable, video instruction can be helpful. Here’s a basic exercise from tai chi that you can do daily to generate more energy:

  1. Stand with your feet shoulders’ width apart and directly under your shoulders. Distribute your weight evenly between both feet and throughout each foot.
  2. Achieve a relaxed, bipolar extension of your spine—imagine a string attached to the crown of your head extending your spine upward toward the sky; at the same time, imagine a weight at your coccyx extending your spine downward toward the earth. Let your arms hang loosely at your sides.
  3. Maintain this upright and extended alignment of your spine throughout the exercise.
  4. Gradually bend into your knees. Step straight ahead with your left foot, placing it, with the toes pointing straight ahead, one or two foot-lengths ahead of the right. Shift 70 percent of your weight forward into your left foot. Turn the toes of your right foot outward to a 45° angle. Your torso should be facing ahead. This position is called the Bow Stance in tai chi, and it is recommended as your initial stance at table side (image 12).
  5. Bend your arms at the elbows to a 90° angle, and let your palms face each other as if holding a beach ball in front of your abdomen. Relax any shoulder tension.
  6. As you gradually shift 100 percent of your weight back into your right leg, begin creating a circle in front of your abdomen by moving your arms down and back. Inhale gently and fully from your lower abdomen (image 13).
  7. As you gradually shift your weight forward 70 percent into your left leg, continue the circular movement of your arms up and forward. Exhale gently and fully from your lower abdomen. The full circle of your arms also will be about beach-ball size (image 14).
  8. Continue the slow, coordinated movement of your weight and torso with the circular movement of your arms for two to five minutes.
  9. Repeat the exercise with your right foot forward.

healthmain-image12-14

Regular Maintenance

As you already know, clip and file your nails regularly, and keep your hands clean, smooth, and free of calluses and rough spots. Protect your hands with gloves when gardening, using harsh cleaners, or doing manual labor. In addition, self-massage of your hands is invaluable for keeping them free of  tension. Use deep, melting compressions of the muscles down to the bone; eliminate trigger points; and wring and strip any accumulated tension from your hands and forearms daily or, at least, weekly.
Use post-event sports massage techniques for any stressed areas of the arms, hands, and pectoral girdle. Increase and clarify energy flow in your hands by regularly and systematically sculpting and stripping each fingertip, including anterior, posterior, and nail surfaces.

Attentive care of your hands is as crucial for effectiveness and vitality of your trade as is advanced or specialized skill enhancement. Avoid debilitating injuries and discomfort by maintaining proper body alignment and extra support for your joints; increasing core, pectoral girdle and hand strength; using a variety of tools; and maintaining your hands regularly. You’ll likely have a longer, more pain-free career as a result.

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Carole Osborne-Sheets is the author of and Pre- and Perinatal Massage Therapy, and a contributor to the upcoming textbook Teaching Massage Therapy, as well as numerous other publications. She is the 2008 recipient of the AMTA Jerome Perlinski National Teacher of the Year Award. The work outlined in this article is adapted from portions of the author’s textbook Deep Tissue Sculpting.

For these and other books, click here.

For information about her certification program, Pre- and Perinatal Massage Therapy, and other hands-on workshops, click here.

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