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.