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The importance of breathing well is not lost on massage and bodywork practitioners. It is valuable to both clients and practitioners, and not just during treatment, but to support those recovering from COVID-19.

The importance of breathing well is not lost on massage and bodywork practitioners. It is valuable to both clients and practitioners, and not just during treatment, but to support those recovering from COVID-19.

Since the onset of the COVID-19 pandemic, massage therapists have received copious amounts of information from governments, health agencies, physicians, professional organizations and educators on managing their practice and keeping clients and themselves safe. At this time, it is unknown how many people who have experienced a COVID infection have been seen by massage therapists, what they report about their reasons for doing so, and the massage treatments provided.

Two well-known symptoms of COVID-19 are fatigue and shortness of breath. These symptoms and others can persist in people even after the viral infection has been cleared.

In a study of long-COVID (post-acute sequelae SARS-CoV-2 infection), four to eight weeks following initial infection large numbers of people continue to experience fatigue (69%), breathlessness (53%), cough (34%) and depression (14.6%)1

Surely, some number of these individuals will seek massage treatment. Going forward, practitioners may see post-COVID clients who are anxious, fatigued and short of breath. Skillful and conscientious treatment may help mitigate symptoms and improve quality of life.

These clients can also provide valuable information to the massage profession. If you provide services to post-COVID-19 clients, consider completing a case report. Completing case reports and case report series are important steps in building evidence. Information on how to prepare a case report is available on the Massage Therapy Foundation website (

The Diaphragm

Anatomically and functionally, the primary muscle of respiration—the diaphragm—is unique. It is a flat, thin sheet comprising two parts: a centrally located tendon and segments of muscle that converge on that central tendon.

The muscular portion is divided into three parts based on attachment site. Fibers of the sternal portion are short and arise as small slips from the posterior surface of the xiphoid process. The costal portion, found on either side of the xiphoid, is made up of several broad muscle segments originating from the internal surface of the lower six ribs. The lumbar portion of the diaphragm has its origin on the lumbar vertebra.

The right side attaches distally to the anterior portions of the first through third lumbar vertebrae (L1-3). The left attaches distally on the first and second lumbar vertebrae (L1-2).

With muscle contraction, the dome of the diaphragm flattens and descends, creating negative pressure in the pleural cavity and an inspiration of air. When the muscle relaxes, the diaphragm returns to its domed resting position and air is exhaled. Additionally, the external intercostal muscles contract during inspiration to expand the chest wall and increase the negative pressure in the lungs.

Relaxed expiration is a passive process where the diaphragm and chest wall return to their resting position. When strong inspiration and expiration are required, accessary muscles of respiration contribute to greater air movement in and out of the lungs. Anyone who has run hard has likely felt improved breathing by placing their hands on their thighs or other nearby surface to take deeper breaths. This action stabilizes the arms and shoulders and allows more muscles to contribute to expanding the chest.

Any muscle that attaches to the sternum or ribs can act as an accessory muscle of respiration, with the sternocleidomastoid, the scalenus, the pectoralis major and minor, the inferior fibers of serratus anterior and latissimus dorsi, and the serratus posterior superior contributing to inspiration while the abdominal muscles contribute to strong expiration.

Massage of the Diaphragm

Techniques for massage of the diaphragm take into consideration two important factors: 1) that only a portion of the attachment of the diaphragm can be reached; and 2) that the abdominal muscles overlie the access.

It is generally recognized that the area of greatest access to the diaphragm is at its attachment on the vertebrochondral ribs, also called the false ribs, on the anterior lateral trunk. To relax the internal and external oblique abdominal muscles, a bolster can be placed under the knees, creating a posterior pelvic tilt.

From this position, the fingers of a cupped hand can be worked gently around the border of the ribs on the same side or the thumbs to the opposite side. Ask the client to inhale then exhale gently to allow for greater reach under the ribs. Moving the fingers along the posterior ribs will engage the diaphragm at its attachment. Finger flexion and extension of the distal joints, gliding along the ribs and stretching comprise most of the massage technique. Keeping the fingernails well-trimmed or using a thin, soft fabric over the skin may be necessary at times to avoid client discomfort. Massage of the accessary muscles is more easily accomplished.

Massage treatment for muscles of the neck, shoulder and abdomen can be important for those with breathing difficulties because of persistent overuse of these muscles. Something to keep in mind is that accessary muscle action is often in reverse of typical muscle origin and insertion function. That is, the insertion is stabilized, and the origin segment is moved. 

In June 2020, Liu Wu, et al, published a protocol in the journal Medicine for a systematic review titled, “The effect of massage on the quality of life in patients recovering from COVID-19 A systematic review protocol.” The paper noted there were no relevant articles for systematic review at the time of publication.2 Wu proposed to study the effect of massage therapy, including tuina and manipulation, on the quality of life of convalescent patients, using randomized controlled trials (Wu, 2020). To date, research remains to be completed.

Stay Informed

The longer the pandemic lingers, the more research and resources will become available.

• One distinguished writer, teacher and author, Ruth Werner, offers insights into the role for massage therapy and how practitioners can increase the ease of breathing and reduce COVID-related anxiety.

• Continue to check for updated research at the Massage Therapy Foundation.

• Read the free-access journal, International Journal of Therapeutic Massage & Bodywork.

• Use Pubmed and, databases of privately and publicly funded clinical studies conducted around the world.

Over time, more information should be collected on the role of massage for supporting post-COVID patients. Until then, proceed carefully using best practices, apply critical judgement in all decision- making and treatments, refer out when appropriate, and collect as much well-documented information as possible. 


1. Mandal, S., & ARC Study Group. (n.d.). ‘Long-COVID’: a cross-sectional study of persisting symptoms, biomarker and imaging abnormalities following hospitalization for COVID-19. Thorax, 76, 396–398.

2. Wu, L., Dong, Y., Li, J., Huang, J., Wen, D., Peng, T., & Luo, J. (2020). The effect of massage on the quality of life in patients recovering from COVID-19 A systematic review protocol. Medicine.

About the Author

Arthur Veilleux, PT, DPT, OCS, was certified as a massage therapist in 1987. He continued a private massage practice and teaching through physical therapy program graduation in 1993. He received a doctor of physical therapy degree in 2006 and served as an adjunct instructor at the Rutgers University Doctor of Physical Therapy program from 2012–2017. He wrote this article on behalf of the Massage Therapy Foundation.

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Address, Breath, Covid19, massage, Shortness, Survivors

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