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Chapter 9 / Massage Strokes andFlow
Figure 9-1. Supine with neck
and knee bolsters.
351
prone or supine position, but most important is maintaining a client-centered focus and modifying your preferences and tendencies to fit your individual client’s needs and
wants. Some clients determine their own positioning for
the massage, asking to turn supine before you are ready
for them to turn over or asking to remain in a side-lying
(laterally recumbent) position for the duration of the session. Unless there are contraindications associated with
the client’s requests, it is appropriate to follow the client’s lead.
You can make clients more comfortable during the
massage by using bolsters and table extensions. These
cushions, pillows, and platforms fit under and around clients’ bodies for extra support and padding. Bolstering
is intended to help clients’ bodies relax with the natural
curves of their bodies supported, but not all clients like
to be bolstered. Position a bolster for support and ask if
the client is more comfortable with the bolster in place.
If not, remove it. You can use pillows and vinyl-covered
retail bolsters or you can fashion your own bolsters out of
rolled or folded towels and blankets. Remember to properly disinfect bolsters after every use or place them inside
a covering that can be properly disinfected after every use.
As an added layer of protection, you can slide bolsters
underneath the sheet that covers the table. Proper sanitation and hygiene are as important to your practice as your
massage. You will learn more about sanitation and hygiene
in Chapter 13.
Several factors govern how you position clients on
the massage table, including their preferences, physical condition, and treatment goals and your preferred
strokes, techniques, and flow. Flow, covered in more
detail later in this chapter, is a routine-like sequence of
steps that leads the massage from one body part to the
next in a systematic, fluid pattern. A flow often includes
directions for specific stroke sequences and techniques
to use.
Supine Position
Supine is the term that describes someone lying on the
back, or spine, face up. When clients are in the supine
position, you have direct access to the anterior surface
of their body and you can incorporate a number of joint
movements into the massage. A small bolster under
the curve of the neck and a larger bolster under the client’s knees support the spine in a more natural position
(Fig.9-1). There is a bolster that is specially shaped to elevate the lower legs, ankles, and feet that you can offer as
an alternative. The supine position is preferred by clients
who do not like confined spaces, whose heads are congested, or who are uneasy and nervous about being on
the table.
Some clients like to talk through the duration of the
massage. Starting the massage in the supine position allows
them to talk freely and use eye contact while speaking. It is
easy to get swept into conversation when clients share their
experiences and emotions, but your job is to treat the soft
tissues, not the emotions. Listen to clients more than you
talk, and stay focused on the soft tissues.
Clients with allergy- and cold-related upper respiratory
congestion may prefer being supine for the duration of the
massage because the prone position can aggravate congestion. In the supine position, gravity enhances the flow of
deoxygenated blood and lymph out of the sinuses to reduce
sinus congestion.
Along with the advantages of the supine position, there
are some considerations to keep in mind. Ceiling light fixtures, especially if they are directly over the massage table, can
be bothersome to clients while supine. Turn off or dim the
overhead lighting and use floor and table lamps, if possible.
Some physiological conditions can also influence client positioning. Just as the prone position may aggravate a
congested head, the supine position may aggravate a congested chest. You can adapt the supine position to clients
352 INTRODUCTION TO MASSAGE THERAPY
A
c
Figure 9-2. (A–C) Prenatal bolstering.
with chest congestion by using a bolster or pillow to elevate their head and shoulders. The supine position is contraindicated for women who are in their last few months of
pregnancy, because the weight of the fetus can compress
the aorta and cut off the mother’s circulation. The sidelying (laterally recumbent) position is the least dangerous
to the mother and fetus, but some women find it uncomfortable. You can bolster these women in a semireclining
position to let them relax comfortably and enjoy massage
(see Fig. 9-2).
Prone Position
Prone is the term that describes clients who are lying face
down on the massage table. When clients are in this position,
the therapist has unrestricted access to clients’ backs and gluteal areas and can easily incorporate joint movements into the
massage. A face cradle and bolsters provide additional comfort
for this position. The face cradle allows the client’s neck to
remain neutral during the massage. Without the face cradle or
a face hole in the table, clients can cross their arms under their
chin or they can turn the neck to the side. If clients choose
to turn their head to the side, encourage them to switch the
direction they are facing once or twice during the prone massage to avoid cramping. Sometimes they naturally turn their
head when they get uncomfortable, but if you notice that
about 10 minutes have passed without a head turn, you can
suggest they change. Most therapists offer clients a small
B
bolster under the ankles (Fig. 9-3A), but clients with a large
chest may be more comfortable with a soft bolster supporting
the upper chest (Fig. 9-3B), and clients with low back pain may
be more comfortable with a small bolster under the pelvis.
Back pain and tension are among the most common client complaints, making the prone position a good
way to start the massage. By treating their back first
and spending a lot of time working on it, you reassure
clients that you heard them explain their condition and
are delivering what they need. Additionally, first-time clients may feel safer and more comfortable if the massage
starts with the prone position because the genital areas
are more protected.
Sometimes the prone position is not the best for the client. Avoid using the prone position for any clients suffering
from head congestion. Massage promotes vasodilation of
the blood vessels as well as the release of histamines, which
are fluids the body secretes to flush out allergens and foreign particles. Gravity encourages extra fluids to drain into
the sinuses and then out through the nose, and clients who
are face down will find themselves in need of some tissues.
Pressure on the face from the face cradle restricts circulation altogether, aggravating any head congestion that was
already present. Clients who are uncomfortable with confined spaces may not like using a face cradle. Clients who
are larger in size or who have large chests present a few challenges to using the prone position. First, their bodies are
much higher off the table, making it necessary to lower your
table for proper body mechanics. Second, you may need to
bolster the upper chest to reduce the strain on the neck. And
Chapter 9 / Massage Strokes andFlow
Figure 9-3. Prone position. (A) Prone with ankle
bolster. (B) Prone with chest bolstering for a large
chest and pelvic bolstering for low back pain.
353
A
B
third, they may have to protract the neck an unreasonable
amount to use a fixed face cradle. A face cradle with a telescoping mechanism that allows the whole face cradle to be
raised can be helpful for a client who is larger or who has a
large chest.
Side-Lying (Laterally Recumbent) Position
The side-lying (laterally recumbent) position describes
when clients lie on their side. This is sometimes the most
effective position for treating clients but requires extra bolstering to keep clients positioned comfortably. It is excellent for working on neck and shoulder conditions because it
presents all of the tissues and allows many different ranges
of neck movement. You need to have bolsters ready and you
may need to give the client specific directions such as:
1. Straighten the bottom leg and keep it in line with the
rest of the body.
2. Flex the knee and hip of the top leg, bringing it forward
in a bent position to rest on a large bolster.
3. Flex the elbow and shoulder of the lower arm, and slide
the hand under a pillow that supports the neck and
head (Fig. 9-4).
This position may be more comfortable for larger cli-
ents, for persons who do not like using a face cradle, or to
Figure 9-4. Side-lying position with bolsters for neck and head,
top arm, top leg, and along back.
354 INTRODUCTION TO MASSAGE THERAPY
give you better access to the side of a client’s neck. It is also
beneficial for working on women who are in the last few
months of pregnancy. When a pregnant woman can no longer lie on her stomach, the side-lying position is appropriate
for the entire massage session. More specific information on
how to perform massage on pregnant clients is covered in
Chapter 12, Special Populations.
The side-lying position is not as popular because it is
somewhat awkward to drape and bolster clients properly
and access different parts of the body. Since this position
can be uncomfortable for clients without sufficient bolstering, you need to make sure that clients feel comfortable and secure when laterally recumbent. Try to keep
your client’s spine aligned along the midsagittal plane.
The bolster under the neck and head should keep the client’s head from laterally flexing in either direction. The
bolster that supports the top leg should be large enough
so that the top leg does not drop down significantly and
strain the hip or back. Some clients cannot relax because
they feel that they may roll off the table during the massage. You can roll up a towel or blanket and lay it at the
base of the back to stabilize them and add a sense of
security (see Fig. 9-4).
Determining Client Positioning and Bolstering
Based on the above information, ask yourself the following
questions when determining how to position and bolster clients for their massage sessions:
• Does the client have a preferred position?
• What are the treatment goals for today’s massage
session?
• Does the client have any condition today that
requires table adjustment?
• Does the client have any condition today that
requires him or her to be in a different position from
the one I usually use?
• Does the client have any condition today that
• Where do I need bolsters or supports today?
• Does the face cradle need adjusting?
Draping is the process of using sheets, towels, and/or blankets to keep clients covered during a massage session to protect their modesty and keep them warm. Once clients are
properly positioned and supported with bolsters, appropriate and modest draping helps them feel secure and comfortable as you uncover specific parts of their body to receive
massage. It may sound simple to keep clients completely
covered during a massage, but it is more challenging than
you think as you expose different body parts and ask clients
to change positions. If you accidentally expose clients during
a massage, which commonly happens during the learning
process, cover them up, make a simple apology, and carry
on. Draping helps you maintain ethical and professional
boundaries during a massage session, and it helps clients
feel safe and trusting enough to relax, even when they are
undressed. Follow sanitation and hygiene standards by using
clean, disinfected linens and making sure to properly disinfect them after every use.
A particular amount of draping may be required by
law in your locale or state, by the licensure or certification
requirements, or as part of the professional standards of
care governed by the professional organization with which
you are affiliated. You are legally bound to adhere to the
regulations, but they represent the minimum. If you feel
that more draping is necessary or if your clients want more
draping, you can ethically and professionally accommodate
those situations. For example, you discover that under the
law and professional standards of care, there are no requirements for draping whatsoever, and a male client wants only
a small towel to cover his groin area. If you are not comfortable with that kind of exposure, how do you handle the
situation? First, you can put a draping policy in your policy
and procedures and/or informed consent as part of your
intake process. Second, you can discuss your preference or
mandated requirement for more draping as well as educate
your client about how massage tends to reduce body temperature. If the client wants to continue with treatment, he
can agree to be covered with more draping. If he insists that
he is perfectly comfortable with so much skin exposed and is
not concerned about body temperature or modesty, you can
refer him to another therapist for treatment.
It is easiest to access clients’ bodies if they remove most
of their clothing, but clients must not feel exposed or vulnerable. Reassure them that they only have to take off the
clothing they feel comfortable removing. As you step out
of the room you can simply say, “I’ll step out while you get
undressed and get on the table, under the top sheet. Please
leave your underpants on as well as anything else you want
Chapter 9 / Massage Strokes andFlow 355
to leave on. I’ll knock on the door before I walk in to make
sure you’re covered with the sheet and ready.” Even if clients choose to wear shorts, swimsuit, or a sports bra during
the massage, you should still use draping. The most important goal of draping is to protect their modesty and comfort
level, because clients who feel uncomfortable or compromised in any way may be distracted, they may not be able
to relax, and they may not get the best results from the massage session.
The core body temperature drops with the parasympathetic (relaxation) response to massage, making it a
good idea to have extra blankets and towels on hand to
cover clients who get cold. You can also have a portable
heater, heated blanket, or massage table warmer for extra
warmth. Being cold during a massage may cause muscles
to remain tight, and it can inhibit the client’s ability to
relax. On the other hand, some clients may get hot during
a massage session due to hormonal shifts that occur with
pregnancy, menopause, and menstruation or after exercise.
You can cool clients down by turning on an overhead or
portable fan, or by uncovering their arms or legs to dissipate heat.
Sheet Draping
Sheets are larger than towels and, as long as you cannot see
through them, they provide better and more secure coverage of the client’s body than towels. This text focuses on
the use of simple, two-sheet draping, but there are several
different ways to drape with sheets. The examples here are
only suggestions; your school or your instructor may have a
preferred method of draping.
When clients step into your treatment room, the draping should already be on the massage table. Sheet draping can be less intimidating than towel draping for clients
because it is so similar to the way a bed is made. First-time
clients may feel familiar with climbing onto the table and
covering themselves with the top sheet, just as if they were
getting into bed. Before you walk into the room, clients can
cover themselves completely with the sheet, which gives
them a sense of control and security.
A basic set of linens for two-sheet draping can include
a fitted sheet to cover the table, a flat sheet to cover the
client, and a pillowcase or fitted covering to cover the face
cradle. A prepackaged set of twin sheets and a pillowcase
provides the basics for two-sheet draping. Purchase several
sets in different colors or patterns, and avoid light, seethrough colors. Flannel and jersey sheets may be softer, but
they tend to stick to each other, making it a bit challenging
when learning the process of sheet draping. You may want
to drape the table with differently colored flat and fitted
sheets to make it easier to differentiate the top sheet from
the bottom sheet.
There is no single acceptable way to arrange your draping fabrics when you expose a body part to work on it, but
your school or instructor may have recommendations or
requirements. Basically, the goal is to uncover different areas
of the body without exposing the genital area, the gluteal
cleft, or a woman’s breasts. In the process of uncovering
parts of the body and redraping them, you can pick up the
client’s arm or leg so the client can stay relaxed, or you can
ask clients to help you by lifting their own limbs. Maintain
good body mechanics by using your legs to lift clients instead
of your back and shoulders. Box 9-1 leads you through some
steps to expose different areas of the body with two-sheet
draping techniques.
When you pull the draping aside to expose an area of
the body, make sure that the sheet is tucked firmly against
the client’s skin. You want to give clients the feeling that
there is a defined line between what is covered by the sheet
and what is exposed. Clients with high levels of modesty
may feel that you can see their covered “parts” if they feel a
breeze under the sheets.
Sheet Draping for Position
Change
Clients typically change position at least once during the
massage, and you will need to help them to make sure they
turn over safely and that their body remains covered. If clients are in the prone position and need to turn over into the
supine position, you can follow the steps in Box 9-2.
The process of turning from the supine position into
the prone position is similar; your position is not as critical
during the turn. You can use the following sequence of steps:
1. Remove the bolsters.
2. Hold the sheet up like a tent, using both hands, and lean
against the table to pin the sheet to the table.
3. Ask the client to turn over, onto the front.
4. If you use a face cradle, ask clients to scoot toward their
heads and rest their faces on the face cradle.
5. Pull the sheet down to uncover the head.
Towel Draping
As in sheet draping, a fitted sheet covers the table, but clients are covered with one or more towels. There are various
towel arrangements you can use to keep the genital area,
gluteal cleft, and women’s breasts covered to protect the ethical and professional boundaries of the session while working on different areas of the body. The simplest approach to
towel draping is to use one large bath sheet with the same
draping techniques you use for sheet draping (Fig. 9-5).
356 INTRODUCTION TO MASSAGE THERAPY
BOX 9-1
Different Areas of the Body
A. Supine position, uncovering abdomen
1. With the client supine, lay a pillowcase on top
of the sheet, over the client’s chest, with the
client’s hands on top of the pillowcase.
2. Client holds the pillowcase while therapist pulls
the sheet down to expose theabdomen.
3. Rest stroke on the client’s abdomen.
Chapter 9 / Massage Strokes andFlow 357
BOX 9-1
Different Areas of the Body (continued)
B. Prone position, uncovering leg
1. With the client prone, push drape medial to the leg.
2. Grasp the edge of the sheet and pull laterally with one hand while
supporting and lifting the client’s knee with the other, and tuck
the sheet under the client’s hip.
3. Offer the client the edge of the sheet to hold for security, and rest
your hands on the client’s leg.
358 INTRODUCTION TO MASSAGE THERAPY
BOX 9-1
Different Areas of the Body (continued)
C. Side-lying position, uncovering back
1. Standing at the client’s back, make sure his
or her top arm is on top of the sheet and tuck
the drape into the armpit and under the chin to
eliminate gaps in draping.
2. Place your hand on the client’s low back, around
the waistband, while pulling the drape aside to
expose the back.
3. Rest your hands on the client’s back.
Chapter 9 / Massage Strokes andFlow 359
BOX 9-2
Prone to Supine
1. Remove bolsters.
2. If using a face cradle, ask clients to scoot toward their feet, out of the face cradle.
3. Reach across the table, gently scoop your fingers under the client’s far shoulder, and lightly pull up on it, saying
something like, “I’m going to hold the sheet up while you roll over this way, onto your back.”
4. Pick up the sheet with both hands into a tent, stand against the table to pin the sheet to the table, and ask the client
to turn over.
5. Pull sheet down to expose the client’s face.
Towel Draping for Position
Change
Turning clients over with towel draping is a little trickier
because towels are smaller, and there is a greater chance of
exposing your clients. As an alternative, you can use multiple towels to provide additional coverage. When clients
need to turn from prone to supine, you can follow the same
steps that you used for sheet draping, but hold the towel(s)
firmly to avoid accidental exposure.
Communication for Client Positioning and Draping
As part of promoting safety and comfort, you may want to
explain the general positioning, bolstering, and draping of
a massage session to clients who have never had a massage.
A person who knows what to expect is better able to relax.
Figure 9-5. Towel draping showing exposed leg.
360 INTRODUCTION TO MASSAGE THERAPY
Even for clients who have had massage before, but are new
to you, it is good to clarify the positioning and draping techniques before or during the session. Box 9-3 presents one
approach for explaining a massage session to new clients.
This is only an example; with practice, you will develop your
own way of familiarizing people with your massage session.
An Example of How to
Describe a Massage Session
to a New Client
On the other hand, the summary of an entire massage
session can be too much for clients to comprehend all at once.
You may find it more effective to explain your bolstering and
draping techniques as you apply them during the massage. For
example, as you start to uncover a client’s back, you can say, “I
am going to pull the sheet down to your waist so I can work
on your back now.” Or, as you finish working on the client in
a supine position, you can say, “I’m going to hold the sheet up
like a tent while you roll over onto your front and put your face
in the face cradle. If you don’t like the face cradle for any reason
at any time, just let me know, and we’ll continue without it.”
When asking clients to change positions or actively participate in the massage, be aware that some directional terms are
confusing for clients who are lying on the table. They may not
be sure whether “up” means toward the ceiling or toward their
head, or whether “down” means toward the floor or toward
their feet. Instead of asking clients to move “up” on the table,
ask them to move their whole body toward their head. Rather
than ask clients to push “down,” ask them to push toward the
floor. When it is time for a client to switch from prone to supine,
you can reach across the table to the client’s far shoulder, scoop
your fingers under it and gently pull up on it while you say, “Go
ahead and roll over this way, onto your back.” As clients roll over
“My goal is to have you comfortable and safe during your
massage session. I will start the session with you lying
face down on the table, underneath the top sheet, with your
face in the face cradle. There is a hole in the face cradle so
you can breathe comfortably. I will leave the room to wash
my hands while you get undressed. You only need to take
off the clothing you are comfortable removing, but know
that your body will be covered by the top sheet throughout
the massage, and only the body part I am working on
will be exposed. I will knock on the door before I come
in, just to make sure you are comfortably situated under
the sheet. I will place a bolster under your ankles for
comfort, and about halfway through the massage, I will
ask you to turn over on your back. I will place bolsters
under your knees and your neck for comfort, and I will
massage your head and neck last. When I am finished, I
will leave the room and give you time to get off the table
and get dressed. There is a stool to use as you step down
off the table, but if you need my assistance, let me know.
Please tell me if you are uncomfortable at any time during
the session, and I will make adjustments accordingly.
For example, clients commonly feel a little cold during a
massage, and I have extra blankets here if you need one.
If you have any questions now or during the massage,
please feel free to ask.”
from prone to supine, it is safer if their back is toward you during
the turn to prevent them from accidentally rolling off the table.
Some clients may need assistance getting on and off the
massage table if the table is too high or their physical condition makes it difficult or painful. You can have a footstool
available for clients who have trouble with the height of the
table, but sometimes that is not enough. Let your clients
know that their safety is very important to you and that it
is not a problem to help them get on and off the table. You
can protect their modesty by showing them how to wrap
the folded sheet around their body before you come into
the room. If you want them in the prone position to start
the massage, the free ends of the sheet should open to the
front of their body, with the ends of the sheets overlapped
in front. Conversely, if they are starting supine, the free
edges of the sheet need to open to the back of their body,
with the ends of the sheets overlapped behind them. After
you have helped the client onto the table, and he or she is
in the proper position, you can open the draping without
exposing the client. (See Box 9-4 for an illustration of
this process.)
For clients who require assistance off the table, make
sure they are in the supine position. If the massage ended
in the prone position, ask the client to turn over to
the supine position. Once in the supine position, you can
use a “diaper drape” technique to help the client off the
table while keeping the whole body completely covered.
It may not be attractive, but it protects modesty. (See
Box 9-5.) There is a simpler alternative to diaper draping,
in which you tuck the sheet under the client’s armpits,
gather the sheet together at the back, and then help the
client off the table. The problem with that technique is
that the sheet is left to drag on the floor, which could
easily trip someone who needs help getting off the table,
such as the elderly, the injured, and those with balance
problems.