Chapter 8 A one-and-a-half-hour routine

CHAPTER CONTENTS
Introduction	74
Begin with the end in mind	75
Working the feet	77
Working the legs	83
Working the hands and arms	103
Working with the patient lying on their side	113
Working with the patient prone	120
Working with the patient sitting	125
Working the neck and head	128

Introduction

Thai Massage includes a vast repertoire of moves. If all were used the massage could go on for more than three hours. In the context of a modern massage practice even a two-hour massage is impractical. For me, both as a giver and as a receiver of massage one and a half hours is ideal. It is not too long and it is not too rushed. The following routine can be completed in just under an hour and a half and offers a complete massage from the toes to the top of the head. The routine is designed for efficiency. In massage terms this means maximum relaxation for the patient with minimum effort from the massage therapist.

This sequence has been refined and tested over many years of teaching and clinical practice. It is suitable for the average patient and avoids many of the more demanding techniques often associated with Thai Massage. These are discussed separately in the following chapter.

Before we begin

As massage therapists we can offer something quite unique in our patient’s life. We can offer a quality of touch and attention that they are unlikely to experience anywhere else. We can offer them the time and space in which to completely let go. This is a rare and special opportunity in anybody’s life. To achieve this aim we need to establish and maintain a relationship of total trust.

If it is not already clear we need to confirm exactly what our patient will pay and exactly how long the massage will last. In this way we immediately free our patient from two common sources of worry – time and money. It helps to briefly explain the process of the massage. We can tell them that we will start at their feet, work their legs, then their hands and arms and on up to the shoulders and back finishing at their neck and head. We can tell them that there is nothing for them to do except let go and relax.

We can offer our patient a glass of water and the use of the bathroom before we begin. We can also tell them to say if they need to go to the bathroom during the massage. Thai Massage moves a lot of fluid through the body and there is nothing less relaxing for a patient than a full bladder.

We ask our patient to lie face up on the mat. We sit cross-legged at their feet. We tell them that they do not need to talk. We tell them that it’s better if they close their eyes and that it’s fine if they dream or fall asleep. We suggest that if anything important comes to mind that they need to share to let us know. We ask them to let us know if they experience any discomfort.

Begin with the end in mind

The last position of a Thai Massage is the yoga posture known as the ‘corpse pose’ or ‘shavasana’. In this posture we lie on our back with our arms open at 45° to our body, palms facing up. Our legs are apart and our hips and buttocks relaxed so that our feet fall naturally outwards. One of my yoga teachers insisted that ‘shavasana’ was the most difficult yoga posture. I used to think he was joking. Now when I see the difference in my patient’s body before and after the massage I understand what he means (Figs 8.1 and 8.2).

Fig. 8.1 Patient before the massage

Fig. 8.2 Patient in the corpse pose at the end of the massage

We do not need to organise our patient’s body to begin with. We just observe how they naturally lie. We observe the relationship of their ankles, their knees, their hips, and their shoulders. We look to see if the legs turn out equally, if their hips rest evenly on the floor. We look to see how their head lies in relation to their shoulders. We do not need to comment on any of this. This is simply curiosity. We are gathering information for the development of our craft. As we work we will aim to keep active this soft and curious observation of our patient. We will also listen for changes in their breathing and for any belly gurgles that give a hint to their relaxation. Sometimes we will be touched by waves of emotions. Again there is no need to comment on this. We are learning to appreciate how our patient’s body changes as we work.

Before we start the actual massage we prepare ourselves. We have a long conversation ahead. We need to know that when we start it is with confidence. We briefly turn our attention to the sensation of our own body. This sensation of our body brings us into the present. We might daydream from time to time as we work but we can always return to the sensation of our body – to the present. The more we can feel our own body as we work the more we can relax. The more we can relax as we work the more congruent becomes our communication. We invite relaxation in our patient by modelling it in ourselves.

Working the feet

Our patient’s feet tell us everything about the way they organise the rest of their body. The shape and flexibility of the feet reflect the tone of the muscles of the lower leg. The tendons of those muscles extend down around the ankles to create the pulls and tensions that give the feet their arches. If the feet are rigid the muscles of the lower leg must be rigid too. This rigidity is bound to continue on up through the upper legs into the back. If we can soften the tissues and articulations of the feet our work is bound to have an effect throughout the rest of the body.

The Thais suggest five lines on the underside of the foot. We can think of these as the five toes extending as metatarsals deep inside the flesh of the foot. We can think of the plantar fascia on the underside of the foot and of the deeper tendons within (Fig. 8.3).

Fig. 8.3 Five lines on the sole of the foot

We gently wrap our palms around the top of our patient’s feet. This is the first contact. Our touch is open and receptive. We let our patient’s body come to us. We wait for a moment, listening to their feet, listening to their body through their feet. We allow ourselves the sense of continuity from the feet, through the legs to the hips and on up to the diaphragm. We position the feet so they are in line with the ankles; so that the ankles are in line with the knees; so that the knees are in line with the hips. We let our patient’s heels rest like fulcra on the floor. We use the long metatarsal bones of the feet as levers. We lean our body weight slowly down through the front of our patient’s feet. We watch and feel as the lengthening extends all the way through the front of the legs to the hips (Fig. 8.4).

Fig. 8.4 Using the feet to lengthen through the front of the legs

Now we wrap our hands around the underside of our patient’s feet so they rest against the balls of their toes. We lean our bodyweight slowly into the underside of the feet. We feel the way in which this long stretch continues all the way up the back of our patient’s legs to their hips and beyond into the lower back (Fig. 8.5).

Fig. 8.5 Using the feet to lengthen through the back of the legs

TIP

We take care to avoid overextending our patient’s toes. The stretch is through the plantar fascia and the back of the legs, not through the toe joints.

We repeat these movements a couple of times. Each time we try to gain more sense of the continuity through our patient’s legs. We let our hands feel for the response in our patient’s tissues.

TIP

We are inviting and following softening and lengthening not forcing a stretch.

We bring our patient’s feet to rest. We suggest a slight turning out through the hips. We take a moment to see if these first movements have made any difference to the shape of our patient’s legs.

We now prepare to work on one foot. The rule is to move to his right side first when working with a man and to her left side first when working with a woman. This rule is based on the relationship of sen ittha and sen pingkhala to the central channel sen sumana. Sen pingkhala on the right of sen sumana is associated with the sun’s energy and with the masculine quality. Sen ittha on the left side of the sen sumana is associated with the moon’s energy and with the feminine quality.

We move both hands to the active foot. We let our thumbs rest on the upper surface of the foot. The upper surface is bony and with little flesh. We do not press hard against it. We use our fingers to work the underside of the foot, softening the plantar fascia and moving all the little joints between the toe bones (Fig. 8.6).

Fig. 8.6 Working the plantar fascia on the sole of the foot

We move our attention to our patient’s toes. With our fingers and thumb we contact the little toe where it begins deep inside the foot. The pressure comes from the fingers underneath the foot. The thumb floats on the bony upper surface. We slowly draw away from the foot towards the end of the toe. We adjust our pressure as we move over the joints and gently bring the movement to a close. The aim is to ease a little space into each of the toe joints as we go.

TIP

As we work the toes we keep our distance from our patient and keep our arms long with the elbow and wrist joints relatively open. In this way we can better relax our arms as we work. Our strength comes from the long muscles of our arms not from the little muscles of our fingers and thumbs.

We now move in between the little toe and the next. With the same contact as before we ease through the tissues, pushing the toe bones apart within the foot. We close gently, squeezing through the webbing between the toes. We continue this sequence; toe-by-toe, webbing-by-webbing, changing our working hand as needs be until we finish with the big toe. Our other hand can assist by mobilising our patient’s foot to smooth the journey of our working hand (Fig. 8.7).

Fig. 8.7 Lengthening the toes

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Some massage therapists finish each movement by flicking their hand as if shaking off something nasty. This is best avoided. It sends quite a negative message to our patient.

Some Thai massage therapists forcibly crack the toes. Again, this is best avoided. It can be dangerous and it keeps our patient ‘on their toes’. We want our patient to relax and trust that we will take good care of them. If we start giving shocks at this point they will never fully let go.

Now that the plantar fascia is softened and the foot bones have been mobilised we slide one hand under the heel of the foot. We use the other hand to grasp the long levers of the metatarsal bones from above. We slowly push the heel up towards the hips while using the toe levers to encourage a lengthening throughout the front of the leg to the hip (Fig. 8.8).

Fig. 8.8 Lengthening through the front of the leg

We reverse the movement to lengthen the back of our patient’s leg. As we bring the foot back to the floor we suggest a slight external rotation at the hip (Fig. 8.9).

Fig. 8.9 Lengthening through the back of the leg

We return to the centre, lightly holding both of our patient’s feet. We look to see if the work on the foot has made any difference to the shape and position of our patient’s leg and pelvis. We take a few seconds to prepare before repeating the entire sequence with the other foot.

When we have finished working both feet we keep contact and take a rest. These rests are well worth savouring. They offer us a moment to:

• check on our own state to make sure that we are still in contact with our own body and not working too hard;

• observe any difference our piece of work has made to the general state of our patient – to their shape, posture, breathing and dreambody;

• prepare ourselves for where we are going next so that we move with certainty and grace;

• renew our sense of listening to our patient’s body (Fig. 8.10).

Fig. 8.10 Preparing to work on the legs

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After receiving feedback from hundreds of students I know that these moments of rest between our activities are often the most profound for our patient. It is as if the patient’s body takes a moment to organise the effect of the work – something it cannot do if we keep on working without a break. Very often we will feel our patient slip deeper into their dreambody.

Working the legs

A colleague studied with Pichet Boonthume, a well-known massage master in Thailand. He insisted that the most important part of the massage was the work on the legs. He told his students to work the legs until they became like jelly.

Some Thai Massage practitioners move from leg to leg as they work the leg lines. In this sequence we work one leg at a time completing all the sen work before moving to the other leg. The reasons for this are:

• we are aiming for maximum relaxation with minimum effort. Working in this way means that the massage therapist does not have to move around so much;

• if we minimise our movements we become less visible to our patient. If our patient is less occupied with our activity their attention turns inwards towards their own inner life;

• when we have finished working one leg in its entirety it should look and feel markedly different to the other. This offers an extraordinary piece of information to the patient’s system as well as a sense of satisfaction and completion for the massage therapist.

As with the feet, the rule is to start with the right leg of a man and the left leg of a woman. Without breaking contact we move to the side of our patient and position ourselves at the mid-point of their lower leg.

TIP

It is best to rest on one knee at arm’s length from our patient. This allows us to work with long, relaxed arms and open joints. The strength comes from the movement of our body and not from the effort of our arms.

Starting at the patient’s heel we feel for the beginning of the 2nd outside leg line. Using both thumbs side by side we lean our bodyweight into the myofascial channel. We feel for the softening of the tissues that lets our thumbs sink deeper. We feel for the movement of the fascia and follow that movement as we sink deeper (Fig. 8.11).

Fig. 8.11 Working the 2nd outside leg line

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The fascia may draw us up towards our patient’s head or down towards their feet. We follow the movement that is there. Our technique is only half the story. The other half comes from our patient’s body as it shows us how to do the technique.

We continue working up the 2nd outside leg line towards the knee. When the tissue becomes bony we change direction and work down the line again towards the ankle. In the course of a massage it is sufficient to work the line four times with the thumbs returning to their starting position at the heel. Each pass aims for a little more depth in the channel and a little more softness in the tissues.

We now move to the 1st outside leg line. We feel for the outer edge of the shinbone just above the ankle. We let our thumbs rest on the bone and then drop off, drawing the tissue into the myofascial channel beside the bone. As before, we move up the leg towards the knee. Each time we sink into the channel we feel for the softening of the tissue and the natural movement of the fascia. We let our thumbs follow this movement into its preferred direction. We release our pressure slowly, leaving the body in the same way in which we entered (Fig. 8.12).

Fig. 8.12 Working the 1st outside leg line

When the channel becomes bony near the knee we change direction and work back down towards the ankle. We work the line five times so that our final pass takes us to the knee. We rest for a moment and prepare to move to the upper leg.

Resting one hand on our patient’s leg we move position so that we sit mid-way along our patient’s thigh. We feel for the route of the 1st outside leg line on the upper leg. We begin by feeling for the little dip at the superior lateral border of the patella. We then feel for the anterior superior iliac spine (ASIS) of the pelvis. The line is not where we would like it to be so we must keep these two landmarks in mind and visualise the line between them. It is best to start with palming.

One hand stabilises the patient’s leg below the knee while the other hand works the line. We place the heel of our hand over the visualised line. We need to direct our pressure horizontally across the top of the femur. We can only do this successfully with a great deal of attention in our working hand. We want to use the contact with the line to introduce a c-bend into the rectus femoris muscle.

TIP

We are not pushing into the muscle. We are lengthening and softening the muscle by bending it, as if bending a green twig (Fig. 8.13).

Fig. 8.13 Palming the 1st outside leg line on the upper leg

As we bend the muscle we feel for its response. At the point where the tissue hardens and resists we let it push us out. We are feeling for the elasticity in the fascial fibres. Sometimes we achieve only a millimetre or two of movement but that is enough. Every body is different.

Once we have a sense of where the line runs we continue to work it with our thumbs side by side. At each position we use the line to introduce a bend in the muscle. At the point of resistance we allow the muscle to push us back out. In this way a rhythm develops – the rhythm of our technique responding to the movement of the muscle. We work the line in four passes, finishing back at our patient’s knee (Fig. 8.14).

Fig. 8.14 Thumbing the 1st outside leg line on the upper leg

We now turn our attention to the 2nd outside leg line. We feel with our thumbs for the anterior edge of the iliotibial band. We press downwards, bending the fascia as if we could roll it under the femur. As before, we follow the movement until we feel resistance and then we allow the elasticity in the tissues to push us out. We continue along this line until the tissue hardens around the hip. We then reverse direction back down towards the knee. We work this line four times, finishing at the knee (Fig. 8.15).

Fig. 8.15 Thumbing the 2nd outside leg line on the upper leg

Now, while still at the side of our patient’s body we lift their leg, bringing the knee up and the foot to the floor so that there is a 90° angle at the knee.

TIP

This angle is important. At 90° the leg is stable and the muscles are at their most relaxed. If the angle is less than 90° the muscles are compressed. If it is more the position feels unstable for the patient and they have to engage their muscles to support the leg.

While holding onto our patient’s leg for support we move position so we are kneeling with our knees either side of our patient’s foot. We keep hold of our patient’s leg at the knee so that they do not need to support it themselves. We arrange our knees so that our patient’s ankle bones are held firmly in the soft creases of our knees (Fig. 8.16).

Fig. 8.16 Working with the bent leg

We are kneeling low. In this position we can do more work on the leg lines of our patient’s lower leg. Now we have some advantages in this work. In response to gravity the muscles are hanging from the leg and because of the position they have less need for tension.

We begin by using the thumb of our lateral hand to work a little deeper into the 2nd outside leg line. We travel downwards from the knee working the line only where it is comfortable for our hand to work (Fig. 8.17).

Fig. 8.17 Working the 2nd outside leg line

We then let out fingers find the 3rd outside leg line at the back of our patient’s lower leg. This is the channel in between the two heads of the gastrocnemius. We use the channel to pull the lateral head of the gastrocnemius out from the mid-line. We will find that there is a natural tendency to lift the muscle as we draw it out. We then combine our movements, pushing in with our thumb on the 2nd outside leg line and pulling out with our fingers in the 3rd outside leg line. When we find the natural rhythm of the muscle it becomes more fluid than solid and, under the effect of gravity, begins to hang like liquid from the bones (Fig. 8.18).

Fig. 8.18 Working the 2nd and 3rd outside leg lines

We can at this point revisit the 1st outside leg line using our thumb to push into the channel between the muscle and bone (Fig. 8.19).

Fig. 8.19 Working the 1st outside leg line with the leg bent

We now turn our attention to the inside leg lines. Although it is possible to work these lines with the leg straight, when we work with the leg bent we can achieve more effect more quickly. We support our patient’s knee with our lateral hand and work the lines with our medial hand. On the inside of our patient’s leg we use our thumb to feel for the 1st inside leg line between the medial edge of the tibia and the muscle (Fig. 8.20).

Fig. 8.20 Working the 1st inside leg line

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This line tends to be more tightly bound than the other leg lines. We cannot push very deep before we feel resistance. We must work with care to avoid causing discomfort.

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