Having a deeper understanding of the mechanical and physiological effects of manual therapies will allow massage therapists to create effective treatment plans.

This understanding will also help support you using several different techniques, and allow your plan of care to be updated as needed quickly and efficiently.

We know massage has numerous beneficial effects for our clients on physical, mental and emotional levels; remember, unconditional touch is the oldest form of therapy.

We all remember being a child and falling down, whether we were running or learning to ride a bike. We would get a cut or a scrape and we would run home, usually crying, to mom and dad.

They would clean the scrape, scratch or wound, put a Band-Aid on it, and give us a hug and a kiss, tell us it would be OK, and we would magically stop crying and run back outside to play like nothing ever happened. That is what unconditional touch can do, and that is what we, as an industry, provide.

Defining Modality

We can define modality for our purposes as “a usually physical therapeutic agent having a beneficial effect on the body or mind producing a useful or favorable result or effect.”

Massage, in and of itself, is a modality. We use our ability to provide unconditional touch to bring about a useful or favorable result or effect for our clients or patients. Whether we realize it or not, we use modalities in most, if not all of our massages. If we understand the basic massage terms, concepts and effects of tension, compression, decompression, shearing, bending, gliding, lifting/kneading, torsion, rolling, and percussion we can build upon them to understand and use modalities.

I look at the body as a whole. When I’m working on a client, I listen to the client describe where pain is felt and observe the body to see the origin of the pain. I think about different techniques that can help me address the area.

No two clients are alike; therefore, I do not treat clients with different needs with the same techniques. I use skin rolling and cross fiber friction over a client’s scar tissue and deep, slow gliding pressure over the hamstrings of a runner.

Read Parts 1, 2 and 3 in this series, “Brick by Brick: 3 Ways Professional Communication Helps You Build Your Practice”; “Brick by Brick: This is How Knowledge of Pathology, Movement, Anatomy & Medication Improves Your Massage” and “Brick by Brick: The Value of Adding Assessment to Massage Therapy Sessions.”

Advanced Massage Techniques and Special Populations

Special populations are groups of people with needs that require different consideration and attention when receiving a massage. Some examples of special populations include pregnancy, geriatrics and diabetes, as examples.

Massage strokes, pressure and techniques often need to be altered when working with persons of special populations. These alterations can include positioning, bolstering, checking tissue integrity, pressure needs, diminished mobility, physical assistance, and indications and contraindications.

Advanced Massage Techniques for Pregnant Clients

When working with pregnant women, depending on the trimester they are in or just how they feel, address changes in the body, like excessive swelling, pain and anything out of the ordinary surrounding the pregnancy, ensuring there are no contraindications. Next, position, and bolster the client for comfort. Check in with the client’s pressure needs and do not assume the pressure needs to be lighter.

The client’s comfort is always first and foremost. Before I assume pregnant clients cannot lie prone or supine, I ask. I also never assume a pregnant woman cannot withstand pressure. Pregnancy is not a pathology and due to changes in the body, my clients have enjoyed deeper pressure between the scapulae, low back and glutes.

Bolstering can get tricky. I always have plenty of bolsters and pillows to place under the client to relieve tension on the belly, back, knees and any other place. The client may have to remain on her side the entire massage with her knees bent with pillows strategically placed to ensure her comfort.

Prior to working with pregnant women, I highly suggest taking pregnancy continuing education. As I mentioned earlier, pregnancy is not a pathology, however, there are contraindications that need special attention.

Advanced Massage Techniques for Geriatric Clients

Geriatric clients may require lighter pressure, positioning, and help getting on and off the table due to diminished mobility. Many need assistance turning from supine to prone and may feel uneasy turning when that far off the ground.

I check in often and use additional lubricant when working with my elderly clientele. I find the tissue is less elastic and can possibly tear from being stretched improperly or with limited lubricant.

Some of my clients are hyperkyphotic, or scoliotic due to osteoporosis, causing their thoracic spine to protrude or one side to appear concaved. Different techniques are useful to address this. I pay attention to the entire body. My client may feel pain on one side of the spine due to tissue pulling on the other.

I don’t want to use heavy pressure, lighter effleurage and petrissage strokes to the taut or concave side can help bring the body back into a more homeostatic state.

Advanced Massage Techniques for Diabetic Clients

Clients with diabetes may have a condition called neuropathy which may affect feeling in the feet or lower extremities. Deeper pressure, especially on the bottom of the feet, may be a local contraindication. The pain can range from numbness to electric jolting pain.

If my client is feeling severe pain due to neuropathy in the feet, I can add bolsters and pillows to ensure the feet do not touch the table. In this instance I often perform the entire massage without having the client turn. I do not want to cause the client any undo pain during massage. I can position myself to work with the client in any position.

Advanced Massage Techniques in Medical Massage

Hospitals and medical facilities are beginning to recognize massage as a useful tool. Patients with cancer, orthopedic pathologies, and chronic pneumonia, among others, can benefit from massage. Pneumonia obstructs the lungs making it difficult to breathe. Depending on the type of pneumonia, patients were given meds and sent home, sometimes after a stay in the hospital.

Massage is now sought out for pneumonia patients. Massage therapists must understand how to position and work with patients prior to seeking referrals. The client should either be side lying or prone with the head lower than the feet. Percussion on the back helps to loosen phlegm in the lungs.

I have had a number of clients who were recovering from pneumonia, and after obtaining medical clearance from their primary care physician they were able to resume receiving massages. In order to help them expectorate some of the remaining phlegm and congestion, I used gentle but firm percussive techniques like cupping on their mid to lower posterior ribs in prone or side lying.

This would have the effect of loosening the phlegm, making it easier for patients to cough and expel the phlegm. After doing this for a few sessions, client were able to expectorate more and more of the phlegm on their own.

More Advanced Massage Techniques

As you understand and become more proficient and comfortable with the basic massage strokes you can begin to apply multiple concepts at the same time and start incorporating more advanced techniques and modalities into your massage.

Some examples are Dermo Neuro Modulation, pin and stretch, and muscle energy technique.

Dermo Neuro Modulation uses gliding and pressure to bring about physiological and neurological changes within the body. Dermo Neuro Modulation uses light pressure, stretching the top layers of skin to flood the brain with a new non-dangerous stimulus to decrease pain and allow freer, more pain free movement. I have found this technique works exceedingly well with people who suffer from chronic pain and those who are very sensitive to even light pressure.

Pin and stretch is a great modality with athletes. Pin down the muscle just proximal of a taut area and then stretch the shortened muscle belly giving a deeper stretch in the affected tissues. The stretch does not have to be held for an extended period of time, only about thirty seconds. This technique uses the principles of compression and gliding. This can help athletes with taut muscles during competition, preparing for competition, or in the maintenance phase.

Muscle energy technique is my favorite modality to use with clients complaining of low back pain — but when asked to pinpoint the pain, they actually point to their buttocks, specifically in the area of the sacroiliac or SI joint, and typically state it hurts when tying their shoe from a seated position.

The client may present with a leg length discrepancy, but this discrepancy is a functional one. Using positioning, isometric contractions, shearing, gliding, compression and decompression, this modality can correct the functional discrepancy and give long lasting relief and freer mobility for the client.

Bring About Changes

Various modalities use unique techniques that will address tissues differently. Individual pathologies require understanding not only what the problem is but also an understanding of the techniques you are using to bring about the tissue changes you desire.

This is Part Four of a special multi-part series on professional development from the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB). This series covers areas that NCBTMB Board Certified massage therapists possess. Read Part One, “3 Ways Professional Communication Helps You Build Your Practice,” Part Two, “Brick by Brick: This is How Your Knowledge of Pathology, Movement, Anatomy & Medication Improves Your Massage” and Part Three, “Brick by Brick: The Value of Adding Massage Assessment to Sessions.”

About the Author:

Matthew Gavzy, PTA, BCTMB, LMT wrote this article for MASSAGE Magazine on behalf of the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB). He has actively maintained his Board Certification for 24 years and is an Approved Continuing Education provider. Gavzy has been a Massage Therapist for 25 years and a Physical Therapist Assistant for 15 years. He currently is a member of the National Certification Board’s Specialty Certificate Committee. Listen to a conversation on Modalities between Matthew Gavzy and Donna Sarvello, NCBTMB’s VP of Educational Support.