Do you have clients who complain of pain related to poor posture? While we can’t directly fix how they stand (this is largely a function of their nervous system), we can give them the freedom to make gradual changes more easily.
This is a guide to accompany my video on massage techniques for posture:
A quick note on communication: If someone comes into your office with a major complex about their posture, the next words out of your mouth could either do a lot to help them, or to add to their self-stigma. This is just like any instance where a client disparages their “bad knee” or “bad shoulder,” as if that part were a villain that they would chop off if they could. You can either adopt their language, or you can use your own.
Client: I get lots back aches because of my terrible posture. Therapist: Massage is great for bad posture! Let's fix that terrible posture of yours.
Client: My posture is crappy and I hate it. Therapist: You do seem a little closed-forward, and that's something we can work with.
As I’ve said before, I don’t want us having to watch every word we say, but the language we use does have an effect. Try to make this a space where body parts don’t get judged.
What can a client expect when it comes to their posture? Well, they might come in expecting you to fix them. They feel trapped in their head-forward, rounded-shoulder posture, and they want you to set them free. They need to know that not only is this not possible, it’s not necessary.
Posture is a poor predictor of pain (here’s a review). If they blame their pain on their posture, it could be helpful to let them know that even people with military postures have back pain (and lots of it), and pain-free spines come in lots of shapes.
That said, working with posture is still something we can do, and it may translate into pain relief for that particular client. This is difficult to prove using the scientific literature (pain and posture are often treated simultaneously, so it’s difficult to say whether one causes the other), but it makes sense. If the posterior cervical and thoracic muscles are having to stay powerfully contracted while at an excessive length, it could be worthwhile to get them out of that sticky situation.
If you and your client make posture change one of your goals, make sure to manage their expectations. They won’t stand like a yoga master, but they may get a few degrees of extra freedom:
… and that can make a difference as far as their comfort and sense of well-being.
Massage strategy for posture
When formulating your strategy, think about what’s tight and short, and what’s long and distressed. There’s a tug-of-war going on, and one team is winning. If the client has head-forward posture with rounded shoulders and an exaggerated thoracic kyphosis, allll sorts of stuff in their shoulders and on the front of their body is tight.
It’s likely that their pecs (both major and minor) are habitually short. Same with serratus anterior, sternocleidomastoid, and the muscles of inspiration (scalenes, intercostals). With rounded shoulders, it’s likely that the pecs, lats, and subscap are hypertonic. Fascially speaking, the entire front of their torso and everything around their shoulders could use some warming and loosening.
What’s long and distressed? The shoulders are protracted and the skull is forward, so: rhomboids, trapezius (all parts of it!), and the erector spinae muscles are all being forced to stay strong and long. If they deal with this for long enough, their distress might refer pain to the shoulder blades, neck, upper back, and head.
While the client is prone
The posterior torso is full of angry tissue, so should we just avoid it and focus on the front? No way. Two reasons:
- That’s where the client hurts, so it would be super frustrating for them if you just ignored it.
- Part of the distress is from nervous system hypersensitivity. Massage is great for getting that to calm down. You could even skip all of this posture reconfiguration stuff and just give them a great Swedish massage and, according to the literature, that would help.
One change that I make while focusing on posture is to bring the client’s shoulders into flexion, like so:
By placing the forearms up on your stool or an exercise ball (or, in this case, a dining room chair), the fascia along the posterior torso and hips goes slack. Combine this with some nice, slow myofascial work, and the client can stand up with a greater sense of freedom.
Make sure to work with the scapula and lateral torso while in this position:
Working with the rotator cuff with the shoulders in flexion like this can really change the feel of the massage, by the way. Experiment with this when dealing with clients with shoulder pain.
While the client is supine
Once the client is face-up, I like to continue to work with the shoulders flexed. You can either let the client’s arms hang above their head, or have them lay their head in their hands (lounging position). I’ll usually start with work along the ribs using broad, flat palmar pressure:
This will require a breast draping with females, and a thorough conversation beforehand. It might sound something like this:
I'd like to work along the front and sides of your ribs. That will require uncovering your abdomen after placing a drape over your chest. Is that something you'd be comfortable with?
See? Not so bad. Once I begin work, I’ll say, “let me know if I’m getting into your personal space,” or “let me know if it seems like I’m too close to your breast tissue.” With potentially sensitive topics like this, it’s best to keep things short and clinical, and to do your best to make sure that your client can voice an objection if they have one.
An alternative would be to do a static traction of their rib fascia through the drape, still using broad palmar pressure. This will still require a conversation beforehand!
I end with work on the pecs. I’ll have a video and post on pec massage techniques soon, but in the meantime: Use movement. As you work with the pecs (broad palmar pressure moving from medial to lateral, petrissage of the pec major, etc), change the angle of the shoulder.
End with some neck work that includes some nice traction. When the client stands up, they should stand a bit taller and with a greater sense of freedom. They might notice a difference in their breathing as well. It’s likely the first time a massage therapist has paid attention to their lateral and anterior rib cage!
If you’re comfortable suggesting a bit of homework, encourage your client to engage in activities that will get them out of their slumped posture. This can just be a general recommendation to stretch more, especially in ways that get their arms above their head, or wide out to either side. If you want to get specific, I’ve found the following stretch to be really effective:
Subtle, right? All you do is clasp your hands behind you, let your arms relax (no locking out the elbows), and then bring the shoulder blades together and down. It will feel like you’re sticking your chest out, and you should feel a subtle stretch in your pecs. I’ll hold it for a second, then repeat once or twice more.
I like this one because most clients will instantly feel a bit of relief in their upper back when they do it. Tell them to do it every time their upper back starts aching, and let them know that this is better than stretching forward. Their upper back wants some slack, not more stretch!
If you have them demonstrate it once or twice, and verify that they feel the stretch where you expect it, many clients will implement this stretch into their routine. I have a much higher rate of compliance with this than with other chest/shoulder stretches.
My secret, sneaky reason that I like this stretch: It’s actually an awareness exercise. By having them let their upper back pain act as a cue to do the stretch, they start to notice their pain earlier and more readily. By having them draw their shoulders back, it gives them a kinesthetic cue about where their shoulders are in space, information that most clients rarely even consider. Yes, I’m an evil genius.
What do you think? Are there any changes you’d make, or techniques you’d like to share? Tell us in the comments!
P.S. I plan to write more of these to accompany other videos. Is there anything else you’d like to see in them? Junk I should leave out? I’d appreciate your feedback!