In order to treat patients successfully, the manual therapist requires high levels of knowledge and skill. Of vital importance in this skill mix is knowing how to use and protect your own body while you work. In this chapter we will offer guidance on the treatment postures and stances best adopted by the practitioner.
Working as a manual therapy practitioner is challenging, and it requires the development and practice of a range of complex skills prior to application in the clinical context. Apart from developing the ability to apply a technique skilfully and appropriately, you also need to learn and practice how to move your own body with an understanding of the laws of physics. This will enable you to work more efficiently on your client with less effort, using stronger forces with less fatigue while exposing your body to less force (Domholdt 2000). Irrespective of how a technique is used with a client, it is of critical importance that you understand and apply the fundamentals of good body mechanics. Your efficiency in using your body during the delivery of the therapy is crucial, not only for the quality of care you provide to the client but also for your own well-being and long-term fitness to practice. Once you understand how to use your body parts as a single entity, you will be able to perform techniques with maximum efficiency (Muscolino 2008).
In the world of manual therapy, however, the study of body mechanics has not yet received much attention. Because of this, many established practitioners, as well as new graduates, often work harder, instead of working smarter; as a result, a good number of them are at risk of incurring career-ending injuries (Muscolino 2006). This chapter will discuss one of the principal concerns of healthy body mechanics: the positioning of your body, particularly your posture and stance, while delivering a therapeutic procedure.
Treatment posture
In manual therapy, good treatment posture means that the practitioner’s body is positioned in a way that allows the whole body to move efficiently and to work effortlessly, without requiring the muscles to generate extra effort. Poor posture causes muscle imbalances and inefficient movement throughout the body. This can lead to the overworking of muscles and unnecessary fatigue when generating greater force (Di Fabio 1992).
Assuming the correct posture during the therapy session enables the practitioner to shift their body weight efficiently from side to side, or forwards and backwards. It also allows for more coordinated action between the practitioner’s body and hands. Taken together, it can be said that a good posture is one in which you feel well-grounded while having the liberty to turn or move (Cassar 2005).
Adjusting or correcting posture is not as easy a task as it sounds; it takes extensive practice and constant reminding. To adopt a correct posture prior to employing a technique, you need to use a combination of components including your body weight, body position and transfer of force (Cassar 2005). In finding your correct posture, you should focus primarily on the following factors:
• your own physical structure
• your body weight and gravity
• your head position
• the height and width of the treatment table relative to the client’s body part being treated
• your contact with the ground or table
• your preferred therapeutic technique.
Physical structure
Your posture must suit your own physical structure. Everyone is different and you cannot simply duplicate another practitioner’s posture; if you try to do so, you may fail to apply the technique correctly. As a practitioner, you have to appreciate your own individual morphology when you apply a technique. Observe other practitioners’ styles and then adapt them to suit you. Finding a style suitable for your own physical structure and build will allow you to have more control over the technique you are practicing in terms of the transfer of force. It will also make the force applied to the patient more consistent and precise, giving greater sensation to the patient while giving you, the practitioner, accurate feedback from the joints and soft tissue in which you are trying to effect a change (Osteopathic Technique 2016).
Body weight and gravity
The practitioner’s body weight plays a significant role in generating force to work on a patient. Usually, this force can be produced in one of two ways: internally and externally (Muscolino 2006). The internal force is created within the body by musculature, but this can be fatiguing as it requires more effort on the part of the practitioner. The external force, on the other hand, is generated with the help of gravity and so requires less effort and causes less fatigue. Therefore, if your goal is to generate greater force with the minimum possible effort, you should learn and practice how to use gravity together with your body weight as much as possible (Clay & Pounds 2003).
Since gravity only works vertically downward, in order to take advantage of it, your body weight should be higher than the patient. This requires setting the table low, so that the client is positioned below the practitioner (Peterson & Bergmann 2002). Because the whole weight of the body is located in the core (i.e. the trunk), your trunk should be positioned above the patient, as much as possible, when you lean to generate forceful thrust/pressure (Muscolino 2006).
Head position
The position of the practitioner’s head has no effect on the delivery of thrust while performing a technique. For this reason, you can keep your head in whatever position is the least stressful for you (Muscolino 2014). However, it has been suggested that holding the head over the trunk is the healthiest posture during a therapy, as this position balances the core weight of the head over the trunk and does not require the neck muscles to support the head (Frye 2004) (Figure 4.1a). Unfortunately, many practitioners have a habit of flexing down the neck and head at the spinal joints in order to observe their client (Figure 4.1b). This leads to an imbalance of the head position and thereby requires isometric contraction of the extensor muscles of the neck to prevent the head from falling anteriorly into flexion (Nordin & Frankel 2001). Eventually, this results in pain and spasm in the posterior neck.
Table height
Correct table height is probably the single most important factor in determining the efficiency of a practitioner’s force delivery. How low or how high a table should be depends on a number of factors:
• The height of the practitioner helps in calculating the appropriate table height. There is some debate about this but the correct height of the treatment table is usually considered to be the half the practitioner’s own height. However, practitioners with longer legs may need to make the table slightly higher. Conversely, practitioners with a longer torso may need to adjust the table slightly down (American Massage Therapy Association 2014).
• The size of the client is another important factor, because choosing a correct table height based on the client’s size helps to reduce strain on the practitioner’s body (Muscolino 2006).
• The client’s positioning on the table (i.e. prone, supine or side lying) also plays a major part in determining the table height. For example, the hips of a client in a side-lying position would be higher than their head and neck. In order to work on the hips in this position, the table would need to be lowered (Frye 2004).
• The therapeutic technique being used on the patient will necessitate adjustment of the table height. If the practitioner needs to create stronger force with less effort, the table needs to be low. However, a higher table height is more desirable when light thrust/force is being applied (Fritz 2004).
