Long COVID is now considered a chronic condition and requires an innovative approach to care. Studies are showing that massage and other hands-on therapists can make a difference for people living with this oftentimes-challenging condition. The first article in this series, “Massage for Long COVID: Part One, Benefits of Manual Therapy,” describes Long COVID and how manual therapy can benefits clients who present with it.

In this article, you will learn about hub spaces, how particular muscles and anatomical structures relate to one another, and how to best work with them to address conditions related to Long COVID.

Restoring Flow & Ease

As Long COVID is systemic, you will work with the intention to restore flow and ease to the system. A key area to understand in this regard are the hub spaces. These are like busy highway intersections where delicate structures like lymph vessels, lymph nodes, blood vessels, and nerves intersect and are close to the surface.

Because so many fluids pass through these areas, they are often places where toxins, such as leftover byproducts of cellular respiration, antigens, or anti-pathogenic particles, pool and settle, potentially creating discomfort and unease. Working very gently in a repeating, slow, and sensitive way over these areas is a way to restore flow to the whole system.

You will notice many of the hub spaces correlate to areas of caution in massage therapy, the backs of the knees and armpits, for example, and for this reason, it is mandatory to work mindfully and superficially, caudad to cephalad and peripheral to center whenever possible to respect the flow of the lymph . Remember, less is more. Less pressure, and at the same time, spending more time there.

In areas that are not caution areas, where deep tissue work is usually applied, you will apply still touch, very slow pressing moves, and perhaps stopping with full-handed presence and light pressure where you will invite the client to breath into these areas.

In this case, it will be important to incorporate some lymphatic drainage techniques with volumetric holds as an integration to your work. Like traffic jams, think long and slow to get the flow into motion again. Those areas that were often passed by before now have become some of the most important junctions to place focus.

Working with Hub Areas

Hub areas are such lymphatic drainage areas as the sternum, knees and folds. Think about opening these hubs (intension goes a long way,) as the lymphatic system carries the immune system. Remember to use a light, pumping touch, always flowing upward or from periphery to center if you are applying lymphatic drainage massage anywhere on the body below the collarbones.

If working the cranium, face, jaw or neck, the flow is always light—but this time, downward. The collar bones are considered the gateway to drainage, as most of the lymphatic fluid that carries the immune system and transports white blood cells that fight inflammation and disease drains here into the subclavian veins underneath the collarbones.

From the cranium, the majority of lymphatic fluid drains underneath the right collarbone. From the body, 90% of lymphatic fluid drains under the left collarbone.

Work the extremities from hand to shoulder and from foot to hip, and work the abdomen in a clockwise direction, upward toward the chest. Use a very light, feather-like touch and keep it very superficial—as though you are massaging the whole body lightly through that one contact area at the level of the skin.

The main lymphatic hub areas to work for addressing Long COVID are: behind the knees; the inguinal and axillary folds (hips and armpits); where the neck meets the shoulders (anteriorly,) and around the base of the sternum. (Your largest lymph node, the cisterna chyli, is located there and pumps lymphatic fluid from the lower half of the body up to drain mainly under the left collarbone.

Another way of helping to move lymph is through pumping motions in specific areas. You can pump the feet, the central upper abdomen, and rib cage (thoracic at ribs three and four.) Think that you are following the beat of your favorite song, rhythmic and equal in the back and forth motion. Traditional manual therapists would apply lymphatic pumping techniques rhythmically to the chests of clients. A scientific study on rats showed that they were able to decrease infection in the lungs with pumping motion applied to the thorax.

Manual Therapy Protocol for Long COVID Clients

With the knowledge of hub areas (where the lymphatic highways meet) in mind, here is protocol:

1. The back and neck. Start with your client prone. Open with a gentle, fluid back massage and work your way to the neck. Massaging the mid-and-lower neck may stimulate relief of shortness of breath.

Focus on the muscles around the middle of the cervical neck, where the phrenic nerve, which powers the diaphragm, originates at the level of the second cervical vertebra. Then massage the muscles around the area of the lower neck (lower cervicals) and first rib (where the shoulder meets the neck). This is where the connective tissue of the lungs (pleura) attaches at C6, C7, T1, and the first rib.

2. Shoulders and upper back Coughing may have caused muscles to tighten in the neck and shoulders. Pay attention to the upper mid-thoracic back where the nervous system is linked to the heart, lungs ears, nose and throat functions.

Think about flossing the muscles around the spine with your movements, such as by using circular movements perpendicular to the spine; and oscillation movements, such as Trager work or slowly wobbling and osscilating your client side-to-side on the table by easing the ribcage from left to right.

Consider using visualization techniques that encourage the client to imagine an ocean in their body and to bring the tide into the shore of the tissues. Invite them to imagine all of the five senses that they would experience while walking on the beach; smelling the salty air, feeling the warm sunshine on their skin, seeing the crystal blue waters, and hearing the wave sounds.

3. Between the shoulder blades. Some clients complain of ringing in the ears, or tinnitus, post- COVID, so focusing between the shoulder blades is useful as this is where the nerves that innervate the ears are connected.

Apply light and superficial touch around these areas as massage stays superficial to these systems, and light work can connect with deeper fascial layers. The key is fluidic, broad touch verses pin-pointed direct touch.

4. Low back to piriformis. Use connecting strokes to work your way down the low back and to the piriformis. You can also work the glutes, as they connect you to the next work. Think of the glutes as the highway to the lower extremities that work hard to power the legs into gait.

5. Legs and back of knees and folding spaces. The back of the knee is a hub area. Long COVID clients sometimes complain of new joint pain so as a massage therapist you will want to think about helping them superficially around the joints to encourage synovial fluids exchange at the level of the armpits, hips, knees, base of neck, and base of sternum.

6. Upper trapezius and collarbones. Have the client turn over and lay supine. Massage the upper trapezius and the soft tissue around the collarbones. Consider the importance of drainage at the thoracic inlet: Coughing can cause discomfort in the lower back and in some cases may cause sacral-iliac joint dysfunction. Shoulder pain may also persist, and headaches may begin.

Cognitive problems, memory issues and an overall increase in stress have also been linked to Long COVID. The trapezius attaches from the sacrum and sacral iliac to the base of the skull.

The complaint of a band-like pain that stretches across the lower back may be coming from the trapezius muscle reacting to the upper thoracic muscles, tightening from the struggle of the lungs. The trapezius may need attention, as it can tighten with lots of coughing, to release the diaphragm.

A lymphatic pumping motion of the ribs can help drain the thoracic cage. Studies have indicated that pumping may help in clear infection. Ribs are one of the most commonly broken bones, so ask the client about any injury to those areas during the intake.

7. Abdomen. With the nose considered 12 o’clock and the pelvis 6 o’clock, work slowly in a clockwise motion in circles on the abdomen. Remember to drape the patient above and below so that they feel comfortable and stay warm. Ask for permission to work on the abdomen, as this area can be sensitive to some people. Explain how improving circulation through touch helps gain balance and stimulate detoxification.

Begin in the center of the abdomen with smaller circles around the umbilicus and work outward, moving gradually to create larger circles as you go outward toward the ribs and sides. Be thoughtful to stay clear of the pubic and groin areas as they are considered caution areas.

At a slow and conscious speed, invite them to do some box breathing. Ask them to breathe in to almost-full capacity, have them hold as long as they possibly can comfortably, ask them to then breath out to maximum capacity and then to breath in again (creating a square image in their mind.) The visualization is to push out “old air” and breathe into “new space.” Educate them that they are breathing in oxygen and pushing out gasses related to metabolic waste.

For those versed in visceral manipulation, those techniques can be applied if no contraindications are present. Freeing the connective tissue linked to the small intestine and liver could prove to be quite helpful. Do not touch the umbilicus. Explain to the client that most of the immune system is found in the gut as well as the greater percentage of serotonin—your happy hormone— production, as well as anti-inflammatory chemical messengers. This may prove to be helpful for those whose main symptom of Long COVID showed up as digestive upset.

The enteric nervous system, or “gut mind,” sends signals to the brain about when to rest and digest, thanks to the vagus nerve, whose main job is to monitor (85% sensorial) how the body is doing.

There are two primary eliminatory systems in the body: the gastrointestinal system and the cardiorespiratory system, which work in tandem with each other like teeter-totters. Some clients complain of digestive upset and residual headaches, which are headaches that have been linked to the gut, post-COVID.

It is worth mentioning the secondary eliminatory systems are the urinary—and the organ of the skin, the massage therapist’s focus. These systems get rid of waste material through opening and elimination. The skin holds the greatest percentage of bacterial flora in the peripheral body, and bacterial balance is key in autoregulation in the body.

All these systems work together to support the autoregulation feedback mechanism, and one may express and compensate for the other. The skin might express heat or inflammation by presenting some new spots, rashes or irritation, for example.

Make this a new part of your intake as well. One system may have overcompensated for the lungs. Embryologically, the nervous system is linked to the skin; hence, massage offers (could offer?) direct relief.

8. Ribs, intercostal spaces and diaphragm. The ribs are like the accordion of the breathing system. They spring open with inhalation in pump-handle movements up and down (ribs one to five) and a bucket-tipping motion in low lower ribs (ribs five to 10), and they relax with exhalation. It’s easy to forget about the intercostal muscles in between the ribs.

The position of the lungs and the fluidity between the lobes have an effect, including discomfort, on the areas they attach to. The pleura, which can pull on the neck and shoulders, can also cause discomfort around the ribs at the base and around the stomach.

The pleura has two layers, the visceral layer (the layer that attaches to the lungs) and the parietal layer (the outside layer that sticks to the ribs). The two layers should have interstitial fluid in between allowing them to glide freely with breath. The pleura webs into the fascia above and around the diaphragm and to the inside of the ribs and may have gotten sticky with the inflammation caused by the COVID-19 infection. Massage can help restore the gliding mechanism of the ribs since science is beginning to consider the matrix of the fascial network as a new secondary system similar to the nervous system that may be more responsible for pain than the muscles https://www.ncbi.nlm.nih.gov/books/NBK493232/

9. Psoas and piriformis. The diaphragm attaches all the way down the lumbar spine and has a direct relationship with the psoas and piriformis muscles, as they all attach at the level of the lumbar spine. Understanding the anatomy of the diaphragm and brushing up on the mechanics of the breath may provide answers for mysterious psoas issues that may be worsening.

The diaphragm is the largest muscle in the body and can influence posture and compensation patterns. The diaphragm inserts into fascial fibers of the psoas muscles, which some people stretch out and work to no end. Then the piriformis can start to fire to compensate, and on and on it goes. Coughing consistently may have created a diaphragm that is stuck in an exhalation pattern, leading to less capacity to inhale deeply.

10. Plantar fascia. More spring in your client’s step creates better absorption in gate and less shock to the system overall. Weight bearing should be on the outer edges, or outer rays, of the feet. Massaging behind the knees, the feet and the area between tibia and fibula may provide a trampoline effect, which helps the lymph flow in the correct direction.

11. Rocking. Gently rock the thoracic cage, shoulders and feet.

12. Final integration. Use long, slow strokes from periphery to center and from feet up to shoulders and from head to shoulders. From QL to the base of the sternum where the cisterna chylii rests, and around ribs seven to nine where the spleen, the main immune organ, sits inside the lungs.

13. Hold. A gentle occipital hold, craniosacral-style, calms the nervous system and opens drainage pathways around the jugular foramen and occipital base. Lean back a tiny bit as you straighten up your posture and do not dig. If clients is tensing their SCOM adjust the hands so that they can fully rest their head on the practitioner’s finger tips and palms.

Carey Benenson Taussig

About the Author

Carey Benenson Taussig, DO (IT), LMT, has practiced manual therapy since 2004. She teaches practitioners worldwide in working with clients online to apply self-massage and employ visualization, among other methods She teaches osteopathic manual therapy techniques to post-graduate manual therapists including massage therapists in-person, both in the U.S. and Europe. Her articles for MASSAGE Magazine include “The MT’s 10-Step Guide to Offering Online Session.” www.threebodiesinstitute.com