A client with advanced cancer was looking forward to the massage session in his home. There had been so many medical appointments lately. So many scans and procedures and hard conversations. This soothing, gentle massage was exactly what he needed — touch without a medical procedure attached it and he couldn't wait to escape it all for an hour.

But there was a challenge ahead. Before the therapist even laid a hand on him, she was concerned that she couldn't get him comfortable on the massage table or even on the client's bed. Cancer had spread to his liver, causing his abdomen to become distended, a condition known as ascites. The added volume in his abdomen, plus this new challenge to his breathing, made the prone position impossible. Even lying supine would most likely cause shortness of breath.

A less-than-comfortable position detracts from the experience of the massage, no matter how lovely and skilled a therapist's hands may be. If someone is lying in discomfort, even minor, annoying discomfort, it may interfere with the potential benefits of the massage session, especially the ability to relax.

Now, imagine lying on the table in not just minor discomfort, but something decidedly more like pain. Pressure in the wrong areas, leads to guarding and tensing up. Compromised breathing leads to sudden changes in position in the search for air. Now, lying down has become work. This is where a skilled therapist can come in to save the session with some mindfulness, creativity and patience.

Position Matters

Most massage therapists are familiar with the two most popular positioning options: supine with a bolster or pillow under the knees and perhaps the head, and prone with a bolster or small pillow underneath the ankles, and sometimes, this is all we may need. But there are many less obvious choices, individualized ones tailored to each client's needs based on their responses to our intake interview questions and how things look on the table during the session.

In oncology massage, there are many reasons for possible position modifications. Anything going on in the abdomen, be it something as serious as liver swelling or abdominal masses to something like GERD, can make prone or supine positioning uncomfortable. In these cases, other options can ease breathing or alleviate pressure. Among these options are:

• Sidelying position with supports.
• Semi-reclining (or semi-recumbent) position, with the client propped up on a stack of many pillows, sometimes as many as five or six (four or five stacked with one lying vertically up against the stack).
• Seated, leaning forward on supports. A client seated at the side of a massage table or kitchen table, with head, arms, and upper torso resting on pillows, can be made comfortable with or without a massage chair available.

More Than Uncomfortable

There are cases where the wrong positioning can set the client up for risk. If a client has a history or risk of lymphedema, a chronic condition whereby an extremity or other area of the body fills up with protein-rich fluid, their arms should not hang off of the side of the massage table, as this can put pressure on axillary lymphatic structures and potentially cause damage or trigger an episode of swelling. Scrolls and wells made with rolled-up towels can gently support and tuck in extremities so that they stay safely on the table. Elevating an extremity with pillows or towels can help to ease that feeling of heaviness or fullness, even if only for a little while.

Clients undergoing cancer treatment may have a chemotherapy port in place. It can be positioned below their collarbone or on their abdomen, or sometimes in other areas of the body. For those clients who have a port placed in their chest, for example, and who really want to incorporate comfortable and safe back massage into their session, they can sometimes lie prone comfortably with the help of a "nest" made with a small hand towel that creates a soft, little depression that the port can fit into so that there isn't pressure being put on a sensitive area.

Good Positioning Supports Sleep

A good night's sleep is good for anyone. But for someone experiencing the symptoms of cancer and side effects of treatment, good sleep is essential. Properly bolstering and positioning someone who needs extra, individualized support may help clients relax more deeply during the massage itself. In addition, the work that you do as a therapist with lovingly supporting an arm, placing a pillow between the knees, or creating a "nest" around a sore spot can be carried into the client's daily life. They can use some of those positioning and bolstering strategies for themselves at home, to help get them more comfortable in bed when they are sleeping.

Perhaps these strategies can be passed along to the client's caregivers, who then get a chance to help by offering a well-placed pillow or towel at home. Good support with towels and pillows can help create a neutral spine for the client when they are on the table, and this position can help minimize pain in cases of bone involvement. Limbs can be gently supported, torsion on the spine can be eased and the neck can be cradled by rolls of soft towels. There is so much versatility and value available with such simple materials, aided by the creativity and caring intent of the therapist.

Don't Rush

As hard as it may be, think of client positioning at a vital part of the massage session, not something to be hastily fussed with and glossed over in an effort to get to the "real" massage. Even though it can take longer with a client with a complicated medical history, it is worth the effort. Take time to communicate about it, so the client doesn't worry or feel pressured to rush the process.

"We're going to spend a few minutes of your session positioning you so you're comfortable. I'll ask you several different times about your comfort. Imagine the eye doctor asking, 'is this better, or worse?' In my experience, this time is well-spent. Once we've settled you into a well-supported position, you'll likely relax better during the massage."

When we take the time to make sure a client is positioned in the best way, when we take those moments to create a soft nest from a towel or to gently add another pillow under the head, and when we do so with 100% presence, our clients often express appreciation. More benefit is possible when the position is comfortable.

Worth the Effort

In the end, the massage therapist worked with the client with ascites in the semi-reclining and then sidelying positions, with five pillows and a few rolled-up towels that she was able to find in his home. The whole process took about 10 to 15 minutes, to get him lying comfortably and supported and bolstered well in each of several positions. Throughout, she worked in a mindful, caring way. She checked to make sure each area was well supported, sliding her hand underneath the support to check for space, then using more towels if the support was not bearing weight.

It didn't leave as much time for the hands-on work as the therapist was hoping for, but she knew her time was worth it when she heard him sigh happily and say, "It doesn't hurt anymore to lie this way. Thank you."