Figure 1. Pin and stretch applied to the elbow flexors is an example of a technique with passive movement.

Orthopedic massage is a comprehensive system used for treating pain and injury conditions affecting the musculoskeletal system. The techniques used in this system of massage vary extensively and are chosen based on how they best address the client’s primary presentation.

One of the most beneficial and useful approaches I have found is active engagement. Active engagement techniques are most helpful when working with clients with specific pain or injury complaints, because they are highly specific. Using movement with massage intensifies the treatment in different ways and in varying degrees.

The Ladder of Intensity

Rick Garbowski, LMT, a teaching colleague from Georgia Massage School, coined the phrase ladder of intensity to describe a framework for active engagement methods. Intensity here means the level of effect of the treatment. In general, with active engagement techniques there is a continuum of effect — the less movement or resistance in a treatment, the less intensity or effect; and the inverse: More movement equals more effect and intensity.

It is essential to understand that the ladder of intensity is not a prescribed progression of treatment. Instead, it merely describes the level of effect of the techniques when applied during phases of client engagement.

Knowing when, why and how to use these techniques in orthopedic massage comes from the practitioner making wise clinical reasoning evaluations based on the client’s condition (nature of tissue involvement, status and recovery stage) and total client picture, history and goals.

Background Principles

The ladder of intensity is a theoretical model that places active engagement techniques on a scale of both neurological and mechanical intensity. It helps determine when particular methods would be most appropriate and during which aspect of recovery they are best used.

At the bottom of the ladder are techniques in which the client is entirely passive as a technique is applied. In the middle of the ladder are techniques in which the client engages muscle contractions and movement during the technique. The top rung of the ladder has the practitioner applying additional resistance to the client’s contraction.

The most common orthopedic massage techniques used with active engagement include variations of static compression, broadening techniques and various forms of longitudinal stripping. Knowing muscle fiber directions and functional anatomy is essential for applying these techniques.

Using movement with massage, especially toward the upper end of the ladder of intensity, intensifies the neurological response, and thus experience, for the client. Simply put, the client can experience more sensation or even pain — so it is essential to communicate with the client, paying close attention to tissue response. Any muscle splinting is a sign that pressure is too much.

Examples of Active Engagement Techniques in Orthopedic Massage

Technique Alone. The first rung on the ladder of intensity is using a technique without any client movement. (Technically this wouldn’t be an active engagement technique, but we use it as the base of the ladder.) The majority of techniques and modalities used in practice are performed this way. This application is particularly helpful for acute injuries or when there is a high degree of sensitivity in the tissues. It is an excellent place to start when determining how a person’s body may respond to pressure or determining their level of pain sensitivity.      

Technique with Passive Movement. In a passive movement technique, the practitioner moves the client’s limb or body part (with no client effort) and applies a specific technique to the tissues being moved. Most often, the technique is applied during lengthening actions.

Technique with Passive Movement

These techniques are particularly helpful for encouraging tissue elasticity and reducing muscle tightness, and thus can treat fibrosity and increase range of motion. For example, one might apply this technique to reduce fibrous adhesions and encourage tissue elasticity in a person’s elbow flexors following an injury where the arm was kept in a sling in a flexed position (Fig. 1).

Technique with Active Movement. The goal of massage is to assist healing in the tissues and reduce client pain. This rung on the ladder is particularly useful for both aspects. In the previous technique, the client’s limb or body part is passively moved during treatment. In this variation, the client actively performs a movement while a massage technique is applied to the target tissues.

The movement may involve a concentric contraction in which the target muscle is being shortened or an eccentric contraction in which the target muscle is lengthening while slowly releasing the contraction (Fig. 2). Lengthening techniques appear to be more effective at encouraging pain reduction and increasing tissue elasticity.

Technique with Active Movement and Additional Resistance. Active movement with resistance techniques is an extension of the previous rung on the ladder of intensity. By engaging additional resistance, treatment can be even more effective, particularly when there isn’t much muscle force required to move the target body part.

Adding resistance to the client’s contraction recruits more muscle fibers, increases muscle density, and increases motor and sensory activity in the muscle even further. The resulting increase in neurological activity helps magnify the effect of descending modulation in reducing pain even further than active movement alone.

Resistance can be accomplished with the use of hand-held weights, resistance bands, or the practitioner manually resisting the movement. The elbow flexors are an excellent example of an area where these techniques can be very effective. The elbow flexors may be a comparatively strong muscle group. However, only a small amount of their force is required to lift the forearm in flexion when the client is on the treatment table. Consequently, it may be helpful to recruit more muscle fibers to get the full physiological effects of an active engagement technique. Deep, longitudinal stripping works well for this issue and is performed during eccentric extension movements (Fig. 3).

Figure 2. Longitudinal stripping is applied along with active eccentric lengthening as the wrist moves in flexion.

This level of the ladder of intensity is most effective when the client is making progress in restoring functional, pain-free movement to a previously injured or painful area; additional resistance is the next step in restoring optimum function. Because a stronger muscle contraction is being engaged, this technique can be more painful, so communication with the client is paramount.  

How Active Techniques Help

Using active techniques in orthopedic massage enhances pain reduction and increase effectiveness in particular situations. These effects are a result of a neurological process called descending modulation or inhibition. We do not have space in this article to discuss this principle thoroughly, but essentially it has to do with how the brain and body process pain.

Technique with Active Movement and Active Movement with Resistance

There is an increase in motor and sensory neurological activity that helps reduce pain and encourage greater muscle relaxation. In descending inhibition, the outgoing motor signals and increased sensory input inhibit some of the neural signals perceived as pain.

In addition to the neurological benefits, active movement techniques help address more of the tissues. Muscle tissue density increases during contraction, which allows the technique pressure to be more effective at targeting the deeper muscle fibers. Increased tissue density means the practitioner does not have to press as hard to achieve a deeper treatment level, which saves them effort and energy.

Figure 3. Deep stripping with additional resistance for the elbow flexors. The client is slowly letting go of elbow flexion contraction as the practitioner pulls her forearm into extension.

Active Engagement Gives You Options

Active engagement techniques greatly enhance a variety of treatment options for your clients. For those looking to improve muscle function or recover from various injuries, these techniques can help clients achieve their ideal treatment goals sooner.

You will also find that learning these techniques will strengthen your understanding of kinesiology and biomechanics, ultimately increasing client results and clinical success.

About the Author

Whitney Lowe, LMT, directs the Academy of Clinical Massage ( He teaches continuing education in advanced clinical massage through the academy, and offers an online training program in orthopedic massage. He is a regular contributor to MASSAGE Magazine and is also a MASSAGE Magazine All-Star (