When I teach continuing education workshops for manual therapy, I avoid teaching proprietary techniques and focus instead on the fundamental skill sets that underlie them. My thought is to emphasize fundamentals, with the intention of promoting critical reasoning so the therapist can figure out how to creatively employ their hands-on assessment and treatment techniques, instead of memorizing specific techniques. Having said that, there are certain technique protocols that rank among my favorites, and I would like to demonstrate a few of them here. We might describe these as my faves. Also included are a few of my pet peeves.

Favorite Technique No. 1: The Three-Quarter Sidelying Technique for the Neck

The first technique I would like to discuss is the ¾-sidelying technique for massaging the neck. I’ve been treating patients now for 40 years, but I still get excited when I have the opportunity to help someone who presents with neck pain and dysfunction. I love treating the neck and I treat it in most every position: supine, prone, and seated; but, by far, my favorite position to treat the neck with the client is in ¾-sidelying position. 

My reasoning is as follows: The musculature of the neck that I believe most often needs to be worked is the one that overlies the laminar groove between the spinous processes and the articular processes (facets), namely the paraspinal transversospinalis musculature, which is composed of the semispinalis, multifidus, and rotatores. In fact, the semispinalis capitis is the largest muscle in the posterior neck and is often overlooked and generally not well appreciated (Image 1). Further, whenever I work with moderate to deeper pressure, I want to use body weight to generate pressure. Putting these two objectives together, it makes sense to have the client in a ¾-sidelying position because this orients the laminar-groove musculature vertically up toward the ceiling so we can position our body directly above and simply sink down with body weight. 

We begin with the client sidelying, facing away from us. We then rotate their entire body approximately 45 degrees away from us (be sure their thighs are not excessively flexed at the hip joints, or the thighs will block the rotation excursion movement) (Image 2A). The biggest challenge is to appropriately place a pillow that supports their head and prevents their nose from being uncomfortably pushed down against the table. For this, I like to use the face-cradle cushion (Image 2B). 

In this position, we can now choose which contact we would like to use. We can use thumb pads, finger pads, or the ulnar side of the hand. But my favorite contact is the forearm. Depending on the space allowed for access, we can use either the larger proximal forearm or the smaller distal forearm (Image 3A). And we have the choice of contacting the client with the medial border of the ulna or pronating the forearm a bit to contact them with the fleshier, softer aspect of the musculature of the forearm. We then position our body to be in line with the stroke and we transfer our body weight from rear foot to forward foot as we lean into the client with body weight, generating the stroke from inferior to superior up the neck (Image 3B). When performing this stroke, it is important to always be mindful of contacting the laminar-groove musculature and not the transverse processes or the spinous processes. At the end of the stroke, we have the choice of leaning into the suboccipital musculature, grabbing and tractioning the occiput superiorly, passing over the ridge of the occiput onto the occipitalis musculature, or a combination thereof. 

A beautiful addition to this technique is to reach around the front of the client’s arm to contact the superior surface of their shoulder girdle (Image 4A). Now, leaning back with that side of our body, depress their shoulder girdle. This creates space to work the neck, and it lengthens the musculature being massaged so it is being worked on stretch (Image 4B). When employing this, it is important to depress the shoulder girdle perfectly in the frontal plane. Do not retract (rotate backward) the shoulder girdle because that would torque the spine. A note regarding body mechanics: The two forces of this technique—one pushing up the neck and the other tractioning the shoulder girdle down—are created by a rotation of our pelvis at the hip joints, pushing forward with the neck-contact hand and dropping down with the shoulder girdle-contact hand. We can even increase the stretch upon the client’s neck by removing the pillow and allowing their head and neck to laterally flex toward the table. It is even possible to increase the lateral flexion of the head and neck by having the client lie with their head off the end of the table. However, this additional stretch can substantially increase the assertiveness of the work and should only be employed on clients who would benefit from the work; no one technique is appropriate for every client. 

Favorite Technique No. 2: Alternating Agonist Contract Stretching for the Neck

Another favorite technique of mine is to perform agonist contract (AC) stretching for the neck, but alternately stretching the neck with a repetition to the right and then the left and so on, whether it is alternating right lateral flexion and left lateral flexion or alternating right rotation and left rotation. Typically, this stretching technique is done with all reps to one side and then all reps to the other side, but I feel that alternating sides is more effective. 

We begin with the client in neutral anatomic position (Image 5A). The client begins the protocol by actively contracting and moving their neck into right lateral flexion, beginning the stretch of the left lateral flexor functional group (Image 5B). The client relaxes as the therapist augments the stretch into right lateral flexion (Image 5C). The client actively contracts, moving their neck into left lateral flexion, beginning the stretch of the right lateral flexion functional group (Image 5D). The client relaxes as the therapist augments the stretch into left lateral flexion (Image 5E). The client actively contracts to move their neck into right lateral flexion again, furthering the stretch for the left lateral flexors (Image 5F). The client relaxes as the therapist augments the stretch again into right lateral flexion (Image 5G). From here, the protocol is usually repeated for 8–10 reps on each side. The breathing protocol is for the client to exhale as they actively contract and move, then finish the exhale as they are relaxed and the therapist augments the stretch. The client then breathes in before beginning the active excursion of neck motion to the opposite side.

Favorite Technique No. 3: Stretching the Psoas Major with Lateral Flexion

Let’s move on to a stretch for a different area of the body: the psoas major (Image 6). As a hip flexor, it is typical to stretch the psoas major with extension of the thigh at the hip joint. However, there are 12 muscles that cross the anterior hip and flex the thigh at the hip joint and would therefore be theoretically stretched with hip joint extension (Image 7A). If any one of these muscles is tighter than the psoas major, it will stop the stretch motion, preventing the psoas major from being stretched. So, the question becomes: How can we focus the stretch within the group of hip flexors to the psoas major? 

The answer lies in finding a difference between the psoas major and the other hip flexors—that difference is that the psoas major is the only hip flexor that also crosses the spine. We can take advantage of this fact by pre-stretching the psoas major with contralateral (opposite-side) lateral flexion of the trunk at the spinal joints before we begin the stretching protocol with extension of the thigh at the hip joint. Therefore, to stretch the right-side psoas major, we ask the client to side bend (laterally flex) their trunk to the left (Image 7B); then when we extend the right thigh, the psoas major, being stretched across both the spine and the hip, will most likely be the hip flexor that experiences the stretch. 

Favorite Technique No. 4: Horizontal Adduction Stretch for the Piriformis

Staying at the hip joint, let’s look at a stretching technique for the piriformis (and other deep lateral rotator musculature) that avoids using the lower leg as a lever, thereby accomplishing the stretch without torquing the knee. It employs horizontal adduction as the stretch motion, but also allows for the therapist to decompress the client’s anterior hip region if pinching pain is experienced, which often occurs when horizontal flexion is used to stretch the piriformis. This technique takes some practice, but once learned it is extremely effective. 

Images 8A–8C demonstrate this technique for the client’s right side. The client lies supine with their right hip and knee flexed and foot on the table. Stand to the left side of the client. Place the client’s right knee under your cephalad-side axillary region (right armpit closer to the client’s head) and reach around to place your right hand on the table (Image 8A). You now have a stable stance with both feet on the floor, both thighs against the table, and both hands on the table (Image 8B). To perform the stretch, simply lean down with body weight, horizontally flexing the client’s thigh (Image 8C). The angle you drop is important; the thigh needs to be brought across the table, but also downward so that the client’s pelvis remains on the table. Otherwise, the stretch moves away from the pelvis and into the client’s lumbar region, and the piriformis will not be stretched. 

A few notes regarding how you can modify this technique. If you are concerned about the client’s knee contacting your breast tissue, you can drape their lower extremity around your trunk so that their lower leg is resting on your back. This also facilitates you contacting their thigh instead of their leg so that the knee joint is removed entirely from the stretch (Image 9). But before moving into this position, get verbal consent from the client after explaining how you will be positioning this technique.

But it is the next modification that makes this technique so invaluable. You can use your hands to open and create space in the anterior hip (inguinal ligament) region if the client experiences pinching pain. Use reinforced finger pads to find the tight hip flexor myofascial tissue that is pinched, and leaning back with body weight, traction the anterior hip to decompress the taut tissue. The trick body mechanics-wise is to lean back to create this traction force while simultaneously dropping your body weight to horizontally adduct the thigh (Image 10).  

Favorite Technique No. 5: Using Body Weight to Perform Deep Tissue Work Between the Scapula and Rib Cage Body Wall

The last technique I would like to present is a protocol to perform deep pressure massage to the tissue between the scapula and rib cage body wall. With the client prone, place your knee on the table under their shoulder girdle. This allows the scapula to fall back into retraction, thereby slackening the tissue between the scapula and spine (middle trapezius and rhomboids). Now, place your reinforced finger pads on the medial side of the scapula and hook them around the medial border. Once you can get a grab on the scapula, simply lean back with body weight, opening and tractioning the scapula away from the thoracic rib cage wall (Image 11). Note: With some clients, it will not be possible to obtain a grab on the scapula. For these clients, more preparatory work must be done before successfully employing this technique.

Conclusion

I hope my favorite techniques resonate with you. Some of these techniques take time to master, so be patient as you practice them. My recommendation with all new techniques is to practice them on healthy clients who are open to you practicing new techniques. Once you have become fluid with the application of a technique, you can begin using it with other clients who need the work. Keep in mind that no one technique will work for every client, so please be mindful with whom you choose to employ each of these options. 

My Pet Peeves

Here are a few of my pet peeves in the world of manual therapy that I feel should be avoided.

No. 1: Don’t Hit My Cervical Transverse Processes 

My first pet peeve is when a therapist works my neck and hits my transverse processes. Ouch! I love deep work, especially in the neck, but I never see any reason to mash soft tissue with deep or even moderate pressure into pointy transverse processes. The therapist often begins posteriorly over the laminar-groove musculature that usually does need work, but then veers anteriorly (perhaps subconsciously following the line of the sternocleidomastoid?) and runs right over my transverse processes with excessive pressure. This is often the first clue that the therapist is not visualizing the structures under the skin with which they are working and is likely performing a cookbook routine instead of being mindful of the tissues of my body. Please visualize the tissues you are working on and be mindful of the transverse processes in the neck. 

No. 2: Don’t Shampoo My Head

The occipitalis in the posterior scalp is a muscle that can be invaluable to have worked with moderate or even deeper pressure. But often, the therapist, who might do deep work in the rest of the body, gets to the head and suddenly works extremely lightly and performs what feels like shampooing strokes to the hair at the back of my head. This is not only ineffective but can be frustrating to the client who experiences neck tension and headaches and wants deeper pressure here. This is also true for the frontalis muscle in the anterior head and forehead region. Please work the occipitalis and frontalis appropriately and avoid “shampooing” the head. 

No. 3: Don’t Work My Hamstrings and Then Stretch My Quadriceps, or Vice Versa

My general rule is to always warm up tissue with heat or massage before stretching it. So, it confuses me when I have a massage wherein I begin by lying prone, and after the therapist works my posterior body, including my hamstrings, then proceeds to stretch my quadriceps, even though the quads have not yet been worked. Or perhaps I begin supine, and after massaging my anterior body, including my quadriceps, they then stretch my hamstrings, even though the hamstrings have not yet been worked. I realize it is logistically easy to stretch the hamstrings when I am lying supine and stretch the quads when I am lying prone, but stretching tissue that is not yet warmed up is usually not only ineffective, but might be deleterious by kicking in a muscle spindle stretch reflex that results in the musculature tightening up, or perhaps worse, actually strains the tissue. Please make sure to always warm tissue with massage before stretching it. 

No. 4: Don’t Use Bony Contacts Over Bony Areas

Using knuckles or the olecranon process of the ulna is a contact that might be stronger for the therapist, but also has a qualitatively different feel for the client. These contacts are bony and hard, and do not feel good when they run over tissue that has bone immediately deep to the skin, for example over the ribs between the spine and scapula. Use of bony contacts here often results in bruising to the periosteum of the underlying bone. Bony contacts are fine over fleshy areas, but not over bony areas of the client’s body.

No. 5: Don’t Work My Anterior Abdomen at the Very End of the Massage

It seems that work to the anterior abdominal wall is almost always offered at the very end of the massage. But massage helps move blood and lymph through the circulatory system, increasing kidney filtration and the need to urinate. So, after 50 minutes or more of massage, the last thing I want to end my massage is pressure placed over my lower anterior abdominal wall. My recommendation is to perform anterior abdominal wall massage earlier in the session.