It has been the premise of this column that every session holds the promise of a lesson to be learned from every client encounter. Some of the lessons are embedded in the process of treatment, but one of the most powerful opportunities for deepening our understanding of the work comes from the questions clients ask. It is in that spirit that this column takes form.

Ms. J. had presented with discomfort in the suboccipital area that radiated superiorly. As I was thoroughly examining possible soft-tissue restrictions that could affect the greater occipital nerve, she glanced upward in my direction.

“May I ask you a question?” Ms. J. inquired. “When you are treating someone, do you have an image in your head of what you are doing, or are you guided only by what you feel?”

I just smiled and shook my head.

“What?” she asked, surprised at my reaction.

“That’s a fabulous question and one I’ve been thinking about a lot lately. The answer to your question is, yes, I am guided by both the image in my head and the feedback from my hands. The comparison between the two is what directs my treatment.”

“How do you mean the comparison?” Ms. J. asked.

“I need a reference point to assess what I feel in my hands. If I asked you to find something with your hands, what do you need to know?”

“I need to know what I am feeling for,” she replied.

“Exactly. When I am palpating tissue, I need the skill to palpate accurately, but the fundamental question is, in relationship to what? If a client asks me if a muscle feels tight, I would, by definition, need to know what not tight feels like. By what criteria do I make that determination? There are so many variables, it’s daunting.”

“And how does the image in your head play into all this?” Ms. J. asked.

“As I palpate your neck, I have a clear anatomical image in my head. What I feel with my hands is then contrasted with that image. Let me give you an example. Have you ever dropped something of value in a crevice, something as simple as perhaps your car keys between the seat and center console?”

“I’ve done that, and it’s frustrating because you can barely get a hand in there,” she replied.

“What’s the first thing you do if you think that’s where the keys are?”

“I look in the crevice to see if that’s where the keys are,” Ms. J. answered.

“Exactly. And when you fish around with your hand to retrieve the key, can you see your hand while you are doing it?”

“No, the crevice is too small to see anything. In fact, I probably do it with my eyes closed.”

“Guided by?”

“Got it,” Ms. J. said. “The image in my head from when I first saw the keys in the crevice. Without that image I’d have no idea what I was feeling. The image gives me context and perspective. But if I got my image by seeing the keys on the car floor, where did you acquire the anatomy image in your head?”

I was stunned at the insight of that question. I had just challenged a student on that very subject. As the student was treating her client’s back, I asked her what muscle she was addressing. She replied with confidence that it was the internal oblique.

“Are you sure? How do you know that with such certainty?” I questioned.

In her response, she cited the various costal attachments of the muscle. When I asked her how she knew where those were, she pulled out her cell phone and pointed to an anatomy drawing.

“It’s a place to start, but that’s a picture—and that’s a real person,” I said, pointing to her client. “What does the internal oblique do when it contracts?”

“It ipsilaterally rotates the trunk,” she answered.

“Excellent! Now keep your finger right where it was while you have the client rotate toward you. Feel the muscle contracting?”

Her face looked blank and confused, as she felt no such contraction. Moving her palpating hand, she discovered the muscle far more superior than she expected. Her client’s anatomy was different than the picture she imagined, so in response she updated her mental image of the internal oblique.

This is an important lesson. Where do we get our images? For me, images ideally come from as many sources as possible and from the various cadaver dissections I have been fortunate enough to participate in. Those experiences showed me how variable anatomy can be; it is an ever-evolving science. Images provide a guideline—a starting point from which our palpation skills can begin—but we need both images and feedback from the hands.

While clients experience a delightful sense of self-discovery through massage therapy, therapists also have access to rich internal mental processes that create a sense of endless wonder and discovery.

 Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars, president of the 20-therapist clinic BodyWork Associates in Champaign, Illinois, and past president of the Massage Therapy Foundation. His clinic, seminars, and research endeavors explore the science behind this work. Visit pnmt.org or email him at doug@pnmt.org.