Comfort. The familiar sniffing and snorting for clearer breathing as our clients rise from a prone position might seem like an unavoidable side effect of a back massage. Side-lying positioning, however, eliminates much of this discomfort—which is especially important for those with colds, allergies, or respiratory compromise or disease.
Propping securely on the side, rather than prone, also avoids the uncomfortable pressure on sensitive or enlarged breasts, anterior surgical or medical equipment sites, as well as gestating bellies. There is less pressing into the table or face cradle for those with delicate skin, and soft, stable support for the potentially fragile bones and inflexible joints of the aging, injured or those with considerable postural deviation.
Using strategically placed pillows and specially designed bolsters greatly improves prone positioning for many clients. However, face down may still be problematic for those with severe lumbar and pelvic pain. Prone positioning shortens posterior musculature, and compresses and anteriorly displaces the lumbar vertebrae and lumbosacral junction.
For most pregnant women, prone positioning also rotates and strains the problematic pelvic joints, and increases strain on the uterine ligaments, some of the very causes of many women’s back discomfort. Deep posterior pressure may further aggravate these structures rather than relieve pain. Instead of potentially worsening clients’ pain, execute a well-organized sidelying position, and the position will facilitate your session rather than hamper it.
Remember, too, that the joint neutral positioning achievable on the side often improves effectiveness with chronic back pain because you’re able to address the multidimensional nature of pain.
You will need to modify your prone and supine techniques for the side-lying client, though doing so opens up other possibilities that will provide great benefit. For example, you might choose to include stretches and other passive and active movements aimed at helping dysfunctional joints and soft tissue. Or, facilitate normalization of nerve function and myofascial organization in painful areas with trigger point, structural integration, Swedish and cross-fiber treatment protocols.
Think, too, of clients who have health conditions or medical treatments that limit their positioning during a massage therapy session. Side-lying position can help you remain effective while also avoiding undesirable and painful pressure on a pacemaker, ostomy bag, chemotherapy port, radiation burn or healing surgical scar, to name a few.
In addition to these physical comfort advantages, side-lying is often more emotionally comforting. Remember that stress and negative feelings often create or accompany physical pain. Side-lying position, more closely than any other, recreates the fetal position that many find reassuring and restful, and can encourage useful and compassionate communication between you and your client, unhampered by the confines of a face cradle.
Patients recovering from heart, breast, abdominal, eye or oral surgeries, as well as pregnant women, are often uneasy about, and most have been advised by their doctors, to avoid anterior pressure. So, when you’re limited to prone and supine, you may be missing opportunities to work with clients who need alternative positioning.
Effectiveness and accessibility. By providing more physical and emotional comfort in your positioning, your work might just become more effective too. You can also adapt and augment your technique repertoire to optimize the increased access that side-lying positioning creates, particularly to hips, shoulders and spine.
Resolving some clients’ issues requires working on structures that are easier to reach from the side: quadratus lumborum, tensor fascia latae, and ITT and thigh adductors, for example. Side-lying position allows you to interact with these soft tissues and associated joints with more ease, accuracy and stability. You will also be able to explore more unique and multidimensional movements when stretching and rocking spine, pelvic and pectoral girdle tissues. Athletes in particular can find this positioning beneficial.
Safety. Both the customary massage positions of face up (supine) or face down (prone) are problematic in some circumstances. With some clients, lying on their back for an extended period results in a drop in blood pressure. Clients most likely to experience this supine hypotensive syndrome are pregnant, have certain heart and lung diseases or compromise, or are overweight.
Typically they feel uneasy, dizzy, weak, nauseated, short of breath or generally uncomfortable if pressure drops due to compression of the vena cava. Others, however, feel no signs but may still be experiencing lower blood pressure. Doctors generally recommend a lateral recumbent position with these patients to maximize their blood circulation and oxygenation.
With no specific research data confirming or negating any type of positioning for prenatal massage therapy, I rely on nursing and obstetrical studies that show correlations between increased intrauterine pressure and complications. How relevant this is to the practice of massage therapy depends on many factors, including: fetal and maternal size, structure, amount of pressure used, duration of treatment, known risk factors, as well as other considerations. Potential danger to any mother and/or baby is enough to make me conservative in my use of prone positioning during pregnancy, however.
Alignment. Fortunately, there are many options on how to get your client comfortably on their side: pillows, specially designed support systems or a combination of both. A few principles for achieving a joint neutral arrangement and some tried-and-true steps to follow to get there will have your clients happily side-lying in no time.
Proper client alignment includes the following:
- Spine paralleling table length and near the back edge
- Space for the pectoral girdle
- Support under the hip and belly, especially important with a gestating or obese belly
- Firm and high supports under the ceiling-side leg to level off that hip, knee and foot
- Often, too, you’ll use comfort supports under the arm, lumbar spine and rib cage, as well as custom provisions for medical equipment, extreme kyphosis or other postural deviations
Availabe equipment for practicing massage in side-lying equipment has both advantages and disadvantages, and client comfort varies with all. Experiment and identify what works for you and, if you use this position frequently, try to develop at least two reliable methods to get your clients to side-lying position.
For example, most clients find the firm stability of the Side Lying Positioning System comfortable and reassuring. Alternatively, the most petite or thin clients might prefer only softer pillows.
Whatever equipment you choose, be ready to make adjustments for individual client needs. For example, clients with pelvic instability at the symphysis pubis often are more comfortable with supports between their legs of sufficient height to level the hip with the entire leg.
Additionally, clients who are living with cancer may appreciate rolled towels to make soft channels of cushioning on top of pillows for maximum “float” and fine-tuning of limb comfort. Practitioners of structural integration, too, often adopt a less-is-more propping attitude.
Draping. Securing the covering sheet for working on the back is relatively straightforward. Maximize access to the entire back with an L-shaped arrangement along the underwear line and the lateral side of the torso.
Anchor this by tucking under the tableside gluteals and thigh. Gaining access to the entire leg and hip is a bit more complex, but I have refined a U-shaped drape and the steps to get there that you can count on:
- Reach across the table for the opposite corner of cover sheet
- Slip that corner between the ceiling-side knee and its supports, from posterior to anterior
- Alternate pulling a U-shape up the lateral thigh and sliding the sheet gently along the medial thigh
- Tuck the sheet end into the U at the lateral pelvis
- Secure the drape under gluteals and thigh against the table
Therapist comfort. Some therapists are discouraged from regularly side-laying their clients because the positioning hurts their body. You need to remember your own alignment and consider working with a table adjusted to a higher height so you can efficiently shift weight in the more horizontally directed line of force that side-lying requires.
Positioning Yourself to Open New Markets
Being able to position your clients in ways different than simply prone and supine can help bring a wider variety of clients to your practice or help you more clearly focus your marketing efforts so you can reach the clients you’re interested in working with regularly.
First, however, you need to equip yourself well and then practice repeatedly to develop ease and grace in the steps of side-lying set-up, draping and client turning on the table. One way to do that is to recognize your current clients who might benefi t from the fresh perspective and novel approach this additional position provides.
Most therapists, for example, have a long-term client whose progress has plateaued. Getting a new angle on your work with that client might solve those stagnations, and give you needed experience and confidence in lateral recumbent work.
Then, point out the unique benefi ts of your sidelying positioning option when marketing your practice’s services. Some potential employment sites and locations to market your side-lying advantage to include:
- Retirement and skilled care facilities
- Radiation and other out-patient oncology treatment facilities
- Oral and cosmetic surgical facilities
- Midwifery and obstetrical practices
- Health and athletic clubs
- Professional and school sports teams
- Chronic pain or back pain treatment centers
- Treatment centers for PTSD and other mental health conditions
When thinking of special populations you might reach, start from your own natural interests. As the population ages, do you fi nd yourself more interested in working with older clients? Are you an avid athlete who would like to reach more clients like yourself with the benefits of massage therapy? When you develop markets that naturally correspond with your own interests, finding and marketing to these client demographics becomes less difficult.
Learning and actively using side-lying positioning gives you one more way to work with a wide variety of clients, from maternity clients to clients facing health problems to athletes. Soon, you’ll find clients and health care providers are eager to schedule with you and you’ll quickly become the go-to therapist in your area!
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