I read a blog post once about a massage therapist's thoughts on working with obese clients. I was expecting some reflections on how to hold a judgment-free zone. Or maybe some insightful ideas on how to bolster and drape that would be helpful. Or even a story about the effects of obesity on joints and soft tissue. But instead I read a disheartening and shockingly cold statement from a person who consciously made the choice to turn obese clients away. He never worked on them. His decision, he recounted, was because he simply couldn't reach the muscle tissue and found it pointless.
Needless to say I immediately wanted to write my own blog. And so here I am. Why a blog, you ask? Why not a video? Good question!
I have made a lot of videos that offer techniques about how to handle a myriad of soft tissue dysfunctions. Most of them we learned about in school - what happens when we sprain an ankle, hold an inefficient posture for too long, sustain a traumatic break - but the complicated pain of being overweight is not so well defined. To demonstrate how to work with obese clients in a video wouldn’t be a simple process, because it is far from a simple dysfunction.
And let me pause here and offer a bit of a disclaimer. I do not think that obesity is a dysfunction. Nor do I think of it as a disease. And I definitely don’t see it as an injury. I see being overweight as the combination of the physical, emotional and chemical processes of life that have wandered down a path that is a bit harder to walk. I also see obesity as a break that happens under the social construct and cultural pressures that weigh on each of us differently. There have been societies who celebrate a larger girth, but for the purposes of this blog, I am writing from the perspective of a modern day American, the culture in which I live. There is a weight to it. And a pain that comes with that. To put it more simply, being fat in today's world might just be the best insight into the complexity of pain than any torn rotator cuff or carpal tunnel syndrome can offer.
There are a couple of good logistical tips (ok... 6) on how to work with a client who is obese. Let’s start here because this is the easy part. Having an obese client is going to mean a couple of things for you as a therapist right off that bat.
1) Lower your table. Your client will be higher which means that your mechanics will have to shift to accommodate. In order to be able to lean in with your body weight, lower the height of your table.
2) Offer to raise the face cradle up. With the extra weight, it can be difficult for a client to allow his or her head to drop into the face cradle if it is at the same height as the table. Lift it to meet their face and offer their cervical spine some relief. (Fun fact this also works really well with female clients who are large breasted)
3) Invest in table extensions that increase the width of your table. This helps your clients' arms to stay on the table as opposed to them feeling like they are working to keep them there. If you don’t have the extensions (or don’t want to invest), use your draping to their advantage. As soon as they get on the table or flip during the session, tuck the blanket around their arms and under their body so the blanket does the holding - not their muscles. This can also feel very nurturing - which, if we’re being honest, we all want to feel!
4) Have extra pillows and towels on hand. Extra body weight can make it uncomfortable to lay on a flat surface. Placing a small rolled up towel under their forearms and hands while they are laying supine can ease the tension from their upper arms and shoulders. Adding a towel to Increase the height of the knee/ankle bolster can feel fantastic as well.
5) While working with your client STAY IN COMMUNICATION. It is a misperception that you have to sink deeper through the fat to get to the muscle. On the contrary, adipose tissue is actually layered in with the muscle (think about what a marbled, fatty piece of meat looks like) and can often be more sensitive than muscle tissue. Sinking deeper is only creating more pain. Not quite the goal here. Talk to your client about what pressure feels good and what is too deep. This is a back to basics reminder but one we could all use.
6) Use broader points of contact. Using a flat palm, flat finger pads, or the soft part of your forearm (the flexor side) is going to feel less painful than a pointy thumb or elbow. You can work deeply with these techniques if that’s what your clients is looking for, it just doesn’t have to be sharp.
Now onto the not-so-easy part.
Being overweight comes with a cultural and social stigma that, even when we don't hold judgment, can can cast a huge shadow on living on this planet. Being sensitive to that shadow is the most effective technique we can offer to our clients.
I read once that being fat is like being simultaneously way too visible and invisible at the same time. Having struggled with weight issues myself, I have felt this harsh reality. No one wants to be noticed for
their flaws and not given a chance to prove their strengths at the same time. And I think that is what it comes down to.
Being fat, more often than not, is seen at a pretty major flaw. And we all know the saying about judgment and books and covers. There are so many other parts to this human who is standing in your office. What we look like is a mere fraction of the big picture. And what is important, and what we all really want, is to be seen for the kindness we carry, the loving relationships we have, the talents that lay deep and often hidden from others.
Here is how I believe being overweight can be the most genuine insight into what pain really is. The experience of having a dysfunction, any dysfunction, is quite often seen as a weakness. A sprained ankle means you can't run. Carpal tunnel means to can't type. Migraines mean live music is out of the question. Chronic back pain means you can't do a LOT of things. Google artistic images for pain... it's produces some thought provoking pictures!
Having to sit out on doing the things you love can often offer a little perspective on how much you are missing. (Not that typing is an olympic sport - but if I couldn't type I would be pretty pissed.) Any injury often means an inability to take part in life being lived. Being overweight kind of covers all those bases. It is not just one limb or body part that is effected. It's not just one activity that becomes problematic. And, most of the time, it is not temporary.
Not being able to do the things you love, being limited in what you can do, can be one of the most painful experiences for any human. It begins to teeter into the vast darkness of loneliness and isolation. Which tips into the grey matter of despair. Which can stumble down the dark chaos of depression. I am not saying this is always the case. There are incredible stories of humans overcoming towering obstacles.
But maybe, just maybe, working with obese clients is more about helping that human being to become - without sounding too cliché - the person they were meant to be. We do this all the time with soft tissue. We listen to the details around the dysfunction and apply the best techniques for each scenario. We work with our clients until they are back to doing what they love or what gives them purpose. And I know that we are not psychologists. But we do offer a safe space. We listen. We hold no judgement. And we Do No Harm. And maybe that is the best technique for this situation.
So keep being the amazing massage therapist that you are. There are so many fantastic modalities out there and so many people who need your healing hands. Just remember that your job sometimes goes above and beyond the new PNF you just learned or the super human strength you possess. Sometimes your best trick is to listen.
“I am grateful that I am not as judgmental as all those censorious, self-righteous people around me.” anonymous