In 1996, Ramit walked into my office. He was big, and he wanted really deep pressure. Oh, no, I thought, he’s going to kill my body. And he did.
Twenty years later, Ramit is still my client. His body hasn’t changed, and he still wants deep pressure, but I’m not in pain when I work on him. (And, no, I’m not taking ibuprofen.) Now, I follow six steps that allow me to deliver deep pressure with the least amount of effort.
1. Lean for Leverage
I embraced the idea of leaning to generate pressure out of necessity. In 2014, I was hanging on by a thread. The orthopedist diagnosed me with cervical radiculopathy, cubital tunnel syndrome, and an unstable left shoulder. These conditions started as old football injuries and were exacerbated by weight lifting and a higher-than-normal volume of massage clients.
My doctor advised me to find a new career. But we’ve all been injured and had to work through things, right? I wasn’t about to give up practicing massage without trying to find options.
Since using my left forearm flared up my conditions, I needed a substitute deep-pressure tool. I tried knuckles and fists. But in order to generate any real pressure with my knuckles and fists, I needed to lean.
Adjust Table Height
This focus on leaning meant I had to lower my table. Why? At my normal table height, there wouldn’t be enough distance between my fists and the client’s body for me to lean my body weight into the client.
Body size also plays into how I set my table height. Ramit is large. Another client of mine, Justin, is small. If Ramit and Justin were lying on a table side by side, the top of Ramit’s body would be an inch or two higher off the table than Justin’s. If I set my table height at Justin’s level for each massage, I’d be giving up an inch or two of leaning leverage when working on someone larger, like Ramit. The best option is to adjust your table height according to who will be on it next.
Also, when a client is lying on the table, body parts stick up at varying heights. For instance, glutes will stick up off the table higher than calves. If you’re focusing on glutes and your table height is set for calves, you may have a leverage problem.
2. Lock and Stack
When I first started leaning, it felt very natural to stack my wrist, elbow, and shoulder joints and lock my knee(s) (Image 1). It also made biomechanical sense to me. When you’re leaning on a client, it’s similar to holding a push-up position. And it’s easier to hold a push-up position with arms locked than it is to hold with arms bent.
It was only later that I learned that leaning into a client while stacking and locking joints had actually been investigated. Edward Mohr conducted a field study where he tested various stances, table heights, and techniques.1 He found that stacking and locking joints while properly leaning required less effort to produce a specific amount of pressure than other techniques that didn’t utilize stacking, locking, and leaning effectively.
3. Segment the Stroke
The leaning, stacking, and locking worked great, but I found myself tweaking my shoulder and neck at the end of a long stroke.
That’s when I started to rethink what makes a stroke relaxing, especially when working at a deep pressure. My opinion in the past was that a relaxing stroke is done at a slow pace and covers a long distance. But over time, I realized it’s difficult, if not impossible, to maintain consistent, deep pressure over the course of a long stroke.
To save my body, I started to test out segmenting a long stroke. For example, instead of doing one long back stroke, I did three smaller ones—upper, middle, and lower.
The result was that I could easily maintain consistent deep pressure because now I was never out of position to lean into the client.
But how did it feel to the person on the table? When I tested the segmented stroke out on clients and other MTs, no one complained. In fact, they loved it.
My next challenge presented itself when I got to the end of the short stroke: How was I going to transition to the next short stroke without making the whole thing seem choppy?
4. Perfect the Pause
No matter how I tried to transition from one short stroke to the next, one thing remained constant—I paused before I made the transition. At first, this concerned me, but when I looked back over how I delivered massage for the past 20-plus years, I realized that I paused during a massage stroke more often than I thought.
For instance, I would pause when I found an area that needed more work. I’d also pause when pressing on a particular area that felt good to the client. And I would pause my stroke when a client would take a deep breath in and out.
Pausing in and of itself was not disruptive to the massage. It was moving to be in position for the next stroke that turned out to be the challenging part.
5. Move Your Feet
One time my wife, Lisa, and I were doing a couples massage together. When we walked out of the massage room, she turned to me and said, “Damn, you’re noisy.”
Lisa was referring to the sound of my footsteps as I moved around the table. And she was right, I was noisy—but fortunately not the kind of noisy that seems to disturb clients.
The reason I move my feet a lot, especially when doing really deep pressure, is because I want to be in a position to effectively and efficiently lean with all my body weight into the client.
As I experimented moving from one short-stroke area to the next short-stroke area, I discovered that no matter what my feet did, the stroke was still relaxing as long as I maintained consistent pressure.
Here’s how that looks. I’m standing at the side of the table doing a double-knuckles stroke in the upper thoracic erectors, medial of the scapula. As I continue my stroke, somewhere around T6, I start to lose my leaning leverage and I need to reposition myself. First, I pause. Then, as I shuffle my feet, my knuckles never leave the client and I continue to lean without changing my pressure. Once I’m in position, I continue my stroke.
By the way, it doesn’t matter if you’re facing the direction of the stroke or not—you can still segment a long stroke. In Image 2, I’m facing the direction of the stroke with both legs locked, and in Image 3, I am not facing the massage stroke and my back leg is locked.
The last piece to making smooth, short-stroke transitions is to keep the same relaxing stroke speed with each short stroke.
6. Pivot and Face
When you’re doing a short stroke, you may be tempted to keep your feet stationary and twist at the waist to work an adjacent area. The problem is that when you do this, you lose leaning leverage.
Instead of twisting at the waist, try pivoting and facing the area you want to work.
Working the quadratus lumborum (QL) is a perfect example of how pivoting can be effective. Say you’re at the side of the table working the lumbar erectors and you’re not facing the direction of the stroke (Image 4). You reach L5 and you want to glide over to the ilium and work the QL attachment.
If you keep your feet stationary and twist, you won’t be able to effectively lean to maintain deep pressure. But if you pivot and turn your whole body to face the QL ilium attachment, you’ll be in an excellent position to lean (Image 5).
From this position, if you needed even more pressure, you could drive from your legs. By driving from your legs, I mean you transfer your weight from the soles to the balls of your feet.
Employ Massage Tools
Massage tools can save your hands when you have to work really deep in a specific area. One of my favorite tools is the T-bar (Image 6), and it’s perfect for the arch of the foot.
First, pin the T-bar between your hand and the arch of your client’s foot. Then, use your body weight to lean in. For instance in Image 7, I’m demonstrating using an open palm hold, bracing my hand against my leg, and leaning in with my torso.
In a Nutshell
Working really deep without being in pain starts with challenging certain massage mind-sets. “I have to do long back strokes when doing a relaxation massage” is one of them.
For deep pressure, a reasonable approach to saving your body is to segment a long stroke. For example, divide a back stroke into upper, middle, and lower, and only work one segment at a time. By doing so, you can effectively lean into the client using your body weight to generate the pressure.
That said, the massage table needs to be low enough so you can lean to generate pressure. When you lean, your shoulder, elbow, and wrist joints should be stacked and your knee(s) locked so you can properly transfer your body weight into the client.
At the end of the short stroke, pause and, while maintaining the same pressure, reposition your feet so you can lean into the next short stroke. Also, pivot and face your target area rather than twist from the waist. Lastly, try a massage tool in places where really deep pressure has a tendency to beat up thumbs, like the arch of the foot.
Put them all together, and I promise you’ll be ready for your next deep-pressure client.
When to Work Deep
Sometimes new clients looking for pain relief ask for deep pressure. My general rule is that I won’t work really deep on a new client unless I’m convinced:
• The client has had deep massages before and has gotten pain relief from this type of massage.
• There’s not a false association. If the client answers yes to having gotten relief from deep massage before, I’ll investigate throughout the massage to see if the client may have falsely associated pain relief with deep pressure.
An example of this could be a client requesting more pressure while I’m massaging them, but is visibly distressed with the current pressure I’m using.
• The client doesn’t have an unusually high pain tolerance.
Combine an unusually high pain tolerance with a false association (no pain, no gain) and you have a recipe for increased pain long after the massage. (That person will not be back. Trust me on that one.)
• There are no bone/tissue contraindications (e.g., fractures, herniated discs, bruises, inflammation) in the area(s) where I’m using deep pressure.
• There are no general contraindications (e.g., vascular disease, client on blood thinners, bruises easily).
• Deep pressure is actually working to reduce pain while I’m doing the massage.
Throughout the massage, I’m checking in with the client to see if I’m evoking a pain-relief response or a distressed response. If I’m unsure, I err on the side of over-communication rather than under-communication.
End-of-the-Day Survival Tips
Sometimes you just have too many clients in one day. And sometimes the last client wants deep pressure. Here are some survival tips based on the countless massages I’ve delivered to Ramit.
Go to the most accessible “In-need-of-pain-relief” spot first.
Ramit’s upper back is rock-solid. It’s usually number one on his complaint list. By going to that area first and delivering the deep pressure he likes, I get him to relax. And this sets me up for tip number two.
Dial back deep pressure in areas that aren’t of primary importance.
For someone who likes deep pressure, do you need to be at that crazy high level all the time? In general, the answer is no. But make sure you deliver the deep pressure in the client’s primary areas of concern.
With Ramit, once I address his upper back (a primary area) with deep pressure, I can lessen the pressure to some degree in the nonprimary areas. However, when I go back to a primary area, I notch it up again.
Alternate between precise deep pressure and broad deep pressure.
If I spent an hour gliding up and down Ramit’s back with deep pressure, I would die—or something would fall off my body. The same is true if I worked his levator scapulae for the whole massage. By going back and forth between precise deep pressure and broad deep pressure, I’m not constantly taxing the same muscles and joints.
If you find a good position for your body when applying deep pressure, stay there.
Unfortunately, you can’t stop a massage and take a break. Instead, you have to find ways to give taxed muscles a rest while you’re doing the massage. If I’m applying deep pressure down Ramit’s spinal erectors with my fists and I get to his lumbar region and find that it’s easy to lean into that area, I’ll pause there. The deep pressure feels good to him, and less strain on my body feels good to me. It’s a win-win.
Note
1. Edward G. Mohr, “Proper Body Mechanics From An Engineering Perspective,” Journal of Bodywork and Movement Therapies 14, no. 2 (April 2010): 139–151.
Mark Liskey is a massage therapist of 24 years, teacher (www.themassageinstitute.net), and business owner (www.pressureperfectmassage.com). His blog at www.makethemostofmassage.com provides massage therapists with the extra knowledge and specific tools they need to succeed in massage.