Community Health Training, Inc.
A Federal Non-Profit Corporation dedicated to bringing no and
low cost health care information to both professionals and the public

Pain Control Without Drugs
Click Here
Detailed Instruction for Hand Positions

These hand and body positions are designed to protect the therapist or doctor performing TPT. In a very large practice with 10+ massage therapists, some with many years of training, we found that doing specific TPT often brought problems to the therapist unless they followed these guidelines closely.

First of all, before we get into specifics, let's cover the basics a little.

You want to let gravity do as much of the work as possible. When you are positioned above the patient, place your body and arms in such a position that you can use straight locked arms pressing down instead of having to use your body muscles to push, pull or apply pressure. For example, when using a hooked hand on the top of the shoulders, lean back with your pulling arm straight instead of trying to maintain a bent elbow. This saves your arm muscles. When working on the back of the body try to position the patient face up with your treating hand under the patient to let gravity pull the trigger point down onto your hand or fingers.

When ever possible try to brace and support the treating hand and fingers with something else. For example, the other hand over the top of the treating hand, the other fingers of the treating hand over the back and top of the treating fingers. Placing the hand in the opposite armpit to create a stable triangle with the elbow pressing into the patient, etc.

It's very important to let the patient tell you when there is a TP and when it begins to change for the better. After all, they are the one's that feel the TPs. Be aware that some patients will want to get rid of the TP entirely before they tell you it's changing. Remind then that it should only take about 20 to 45 seconds and that the pain during the sessions will never go away completely.

Never bend a finger or thumb backward unless it's supported and strengthened with another body part. It can ruin your hand.

When you use a tool of some sort DO NOT use it for the first few sessions on a new patient. They have to learn what a TP feels like when it's there, when it begins to change for the better, and know how much pressure is acceptable before they can direct your actions. The first few sessions are training for the patient to give direction to the therapist or doctor. If you use a tool initially, you won't be able to control the pressure as well as when you use your own fingers.

Be aware that a bony prominence, cyst, scar nodule, calcific deposit, bullets, and other hard things in the body can feel like a TP to both you and the patient but it's the change you're looking for to define it as a true TP.

The Trigger Point CD has much more detail, including short movies, to give even greater detail than is prvided here.

Single Fingertip (1F) - This is used when the TP is deep in fairly soft tissue like the space between the scapula and clavicle at the top of the shoulder. Place one finger in position as you bend it forward. Overlap the other fingers over the treating finger for support. This is use, also, when a larger "hand tool" doesn't fit as in the space just behind and below the ear for TMJ work or under the neck for the cervicals in a patient face up position.

Thumb Tip Fist Overlap (TTO) - This is used when you want only one strong thumb tip to be applied. Using the thumb unsupported is very bad for your hand. Make a fist with the fingertips as far down toward the wrist as possible. Overlap the thumb while bending it forward across the 3rd bone from the tip of the index finger.

Double Thumb Flat (DTF) - this is used when you want to cover a fairly large area as in the paraspinals close to the spinous processes. In this positions the fingers are spread outward and not tucked into fists. Place the thumb tips tip to tip with the thumbs bent backward so that the flat part of the first joint is flat on the patient. This is one of the few times you will bend a joint backward. Once in position you should have a "hand tool" that extends from the first joint of one thumb through the tips to the first joint of the other thumb for a distance a two to three inches. This allows you to scan a shallow region quickly. Instead of checking each thoracic vertebrae (2 sides of 12 vertebrae for 24 positions) you can actually cover two or three levels at a time for only 4 to 6 spots on each side for a total of 8 to 12 spots to check. When doing the paraspinals you want to feel the SP against the side of your thumb so that you are in the groove between the Spinous Process and Transverse Processes.

Double Thumb Post (DTP) - This starts similar to the DTF but as soon as you have the tips of the thumbs together you bend the coupling backward so that the thumbnails and backs of the first joints end up firmly touching back to back. The firm touching is critical to protecting your thumbs. In this positions the fingers are spread outward and not tucked into fists. This is one of the best, most useful and protected "hand tools" you can use. It's used for all deep tissue work. By making sure your thumbs stay touching you will be able to work longer without discomfort or problems developing.

Squeeze (SQ) - This is used whenever you can grip the muscle away from the bone. The idea is to cover as much of the muscle as possible at one time. Occasionally you will want to do a Double Squeeze (DSQ) by using either the hands side by side as in the calf or biceps area or one overlapping the other for added support and strength as in the feet. Use the flats of the finger prints against either the palm, the base of the thumb or the flat of the thumb print. This works well at the top of the shoulders.

Pinch (P) - This is used when you need to be specific on a thick muscle you can grip or need to pull the muscle away from the body as at the SCM or in the feet. Pinch the muscle between the tips of the fingers and thumb with your hand in a "C" or "O" pattern. This may use the other hand for support to help strengthen and sustain the grip.

Hooked Hand (Hook) - Use this for the top of the shoulders, any time you are reaching across the body to pull back or need to treat an area that isn't low enough for you to straight arm it. Form your fingers into a hook with the fingertips flat as if they were resting on a table surface. Occasionally you will want to overlap the fingers and use one or two for actual contact while the others support. Sometimes you may want to use all four finger tips but allow them to roll the pressure from one spot to another without having to move your hand as in the cervical region in a patient face up.

Double Hand Overlap (DHO) - This is used primarily in the abdominal region when you need to go deep and slow as on the colon or psoas muscles. The thing most people do when pressing down into this soft area is to use their finger tips and bend the fingers backward to lock them in position. This is very bad for your hands. Use only one set of fingertips for contact. Bend the fingers slightly forward. Overlap the fingers of the other hand onto the back of the treating hand fingers (one for one) but with the other hand cupped slightly more than the treating hand. This allows the treating fingers to curve forward with support so that you can prevent stressing the finger joints. You hands should look like the shadow puppet of a fish with fins (thumbs) sticking out to the sides.

Elbow Triangle (Elbow) - When you can stand or sit in a position next to the patient (usually face down) you can save your hands by using your elbows. The best way is to hook the thumb of the treating elbow under the opposite armpit with the fingers grasping the deltoid muscle. This give a very strong supported triangle with the elbow as the tip against the patient. Start by locating the TP with a thump tip, then circling the area with the other hand index finger and thumb and then placing the point of the elbow into the circle. Use the other hand to stabilize and guide the elbow. Doing this correctly allows you to apply good pressure with almost no exertion on your part at all.

Forearm Roll (FR) - This is used in the legs of the patient. With the patient either face up or down you stand or sit beside and perpendicular to the patient. Place the bone on the downside of your forearm onto the muscle in the leg you want to treat so that the elbow is fairly close to the muscle but not on it. Now clasp your hands together for support and guidance. Slowly roll the bone of your forearm across the muscle you are treating. You can actually rock back and forth and move up or down the muscle at the same time thus saving you hands from overwork.

First Knuckle (1stK) - Whether you use one or several fingers you want to make absolutely sure your "hand tool" is a very straight rod from the elbow clear to the knuckle tip you are using. Make sure there are no bends in any of the wrist or finger joints. When doing this it's often a good idea to use the other hand to grasp the treating hand wrist for added support and guidance. This same technique can be used with the TTO.

Fist Bump (FB) - This is used when you don't want to use your muscles supporting your body while you press down into the patient. After all, you do use a lot of muscles throughout your body just to keep yourself standing upright and to prevent your collapsing. Make a fist such that the knuckle of the index finger is held higher than the rest. This is usually done by clenching the fingers and placing the thumb under the index finger instead of beside it as the fist lies on the table top. Now have the patient roll slightly so that you can position your fist under the body then have them roll back down on your fist. Once in position simply clench the fist a little tighter and the knuckle will pop up a little higher for better therapy. A modification of this is to use the fist on it's side with the little finger down and the thumb up. Do the same thing but flex the thumb to make a higher knob.

(Return to top)