Save Your Hands!® Injury Prevention & Ergonomics for Manual Therapists

In my last post I wrote about how much I missed the warmth of the sun during the winter and spring. The sun also provides light, which is more important to us than simply allowing us to see. In addition to stimulating the retina and optic nerve, light also affects the endocrine system. Bright light increases the levels of cortisol in our bodies, which increases our arousal level during the day. Decreasing light levels trigger an increase in melatonin, which helps us to feel sleepy at bedtime.

Sleep problems can occur when we don’t get enough bright light during the day, or when we get too much bright light in the evening. Many massage therapists work in low light levels, since this creates a relaxing environment for the client. Massage rooms are most likely lit with a “warm” light, such as an incandescent bulb or artificial candle. “Cool” lights, such as daylight fluorescents or LEDs may seem harsh, but the blue end of the spectrum that they provide is important for increasing wakefulness during the day. Of course all artificial light is just that – artificial. Natural daylight, as long as we avoid over-exposure, seems to be the best thing for our well-being, both physical and psychological.

So, if you’re not having any issues with sleep or mood, you probably don’t need to make any changes to your light exposure. But if you are having sleep problems, you might try getting more natural light during the day, and using low level, warm lighting in the evenings.

I live in the Pacific Northwest, where we have a lot of things that make for a great quality of life. Abundant sunshine, especially in the winter and spring, is not one of them. The cold and damp can result in a lot of sore and achy muscles, which keeps the local massage therapists busy. The downside is that the massage therapists themselves can also develop the same sore and achy muscles. I speak from personal experience.

I’ve noticed that I can often go an entire summer without really needing a massage, even though I’m even more active than usual during the warmer months. In talking to other massage therapists, they’ve also noticed that their business decreases during the summer. It seems that the warm, sunny days help to keep muscles loose and relaxed.

I’ve found something that helps to replace the therapeutic effects of the sun during the cold, dark winter months. There are now infrared heating pads that are commercially available. These heating pads produce heat that penetrates deeply into the muscles, relaxing muscles and lubricating fascial tissues. Infrared heat may even reduce inflammation and draw moisture into the tissues to help speed healing.

I’ve been using infrared heating for a couple of winters now, and I have found it very beneficial. The heat has a very relaxing quality to it, unlike traditional heating pads that just seem to make my skin hot and itchy. Infrared heating pads use a lower level of electric current, which also means that they generate lower levels of electro-magnetic fields (EMFs). I use infrared heating pads both for self care, and to warm a client’s muscles before working on trigger points.

In the interest of full disclosure, I have no ties to any manufacturers or vendors of infrared heating pads. I’m just happy to have a way to replicate the warmth of the sun when I seem to need it the most.

Instability can lead to unnatural positioning, one of the main factors that contributes to work-related injury. For this reason, avoid using any technique that puts the arms and/or hands in positions that are hard to control, or causes them to wobble.  Using broad, flat areas, like the forearm or front of the fist or knuckles, will give you the most stability.  The thumb and fingers are the most unstable parts to use, since they tend to buckle and wobble when pressure is applied to them.

Enhance stability by reinforcing your hands, wrists and fingers. The more stable the wrist or finger joints are, the less the muscles have to work to keep the joints in alignment. The added stability distributes stress more evenly, and allows the muscles to relax, since they no longer have to work so hard to maintain stable positioning.

Try using your free hand to enhance stability at the wrist. When using your fingers, create stability by using at least two fingers at a time: never use just one finger to apply pressure. When using a flat palm, place the other palm on top of it. Keep the bottom hand soft and relaxed, so it can palpate properly and retain its sensitivity.  Think of the bottom hand as the “palpating hand”, and the upper one as the “power hand,” the one that propels and creates the pressure of the stroke. You can use this same technique when you apply pressure with your fingertips.

I should probably clarify – I don’t actually have a problem with Daylight Savings Time itself. I like the extra daylight in the evening, since I have time to come home from work, eat dinner, and still do something outside.

It’s the time change in the spring that I don’t like. I don’t do well losing an hour’s sleep. And I’m not alone in this. The “spring forward” time change has been associated with negative outcomes such as mood changes, higher rates of serious workplace injuries, an increase in heart attacks, and a spike in fatal car crashes.

It doesn’t seem likely that all of these effects could be from the loss of just one hour’s sleep. It seems more likely that the time change is the tipping point for people who are already a little short on sleep, something that’s all too common these days.

My strategy for dealing with the time change? I’m taking a vacation day on Monday. And getting a good night’s sleep.

I saw an interesting on-line video recently. There’s a link to at the end of this blog. (It’s a 30-minute video, so I want to give you a little preview of it so you can decide if you’re interested in watching it or not.)

The speaker in the video is presenting to an audience of “creative types” about fatigue and the importance of sleep, rest, and downtime to maintaining energy. One of the theories he talks about related to ‘ultradian rhythms.’ These are our bodies natural rhythms that have relatively short cycles, about 90 minutes, when compared to ‘circadian rhythms’, which are related to our wake/sleep cycles during daylight and nighttime hours.

Ultradian rhythms have been studied more in sleep research than during waking hours, so I’m not as convinced of their influence on our work as the speaker seems to be. Certainly most of us experience periods of higher and lower physical and mental energy during the day. I seem to fade out a little around 10:00 in the morning, and then again an hour or two after lunch. A lot of people attribute the post-lunch sleepiness to the energy requirements of digestion, but I seem to have a lot of energy an hour or two after eating dinner (as long as I don’t eat too much or drink too much red wine).

Those who are convinced of the effects of these body rhythms recommend a 20-minute break every 90 minutes to 2 hours to re-energize. The speaker in the video certainly makes some good points about focusing on work when you’re working, but then letting go of work entirely during breaks in order to truly rest and re-energize. The common practice in spa and massage practices of 50-minute appointments with 10 minutes in between to turn the room over doesn’t really allow for this type of recovery.

My own feeling on this is that each of us likely has our own unique rhythm. If we can get in touch with that rhythm we can better decide whether certain work-rest cycles are going to energize or deplete us.

Here’s a link to the video. Before you go watch it, please share any strategies you have for keeping your energy levels up by leaving a comment.

If you’ve been reading this blog for even a short while, you’ve learned the importance of self-care and injury prevention to your career longevity.  But did you ever think about how learning about this subject could actually make you a better therapist?  Here are 10 ways this can happen:

1. Understanding the risk factors for work-related injury for yourself also helps you better understand why your clients experience adhesions, soreness and injury as a result of their own work;
2. Learning good body mechanics can help you produce smoother, more controlled, more self-assured strokes that actually feel better to your clients;
3. Learning to use larger muscles and body weight to deliver your strokes means you can use less effort in your massages – you’ll be less tired and have more energy to devote to your clients;
4. Getting in better physical condition (an essential part of your injury prevention efforts) will also cut down on your fatique and give you more energy to devote to your clients;
5. Designing your treatment space to be more ergonomic and safer for your own work will likely make it a more comfortable and safer space for your clients as well;
6. Once you have understood that it takes a multifaceted, holistic approach to truly prevent injury, you can pass that knowledge on to your clients: it’s just as true for their own health as it is for yours;
7. By looking for alternative techniques that are less taxing and more adapted to your own body, you’ll learn to be flexible and adapt your techniques to each client, rather than just doing the same routine you learned in school for all your clients;
8. As you learn about good nutrition and other best practices for taking care of your general health (an important part of injury prevention), you can share this information with your clients to help them take care of their own general health (of course, I mean just “share”, not “prescribe”, which is outside your scope of practice);
9. Developing more in-depth understanding of musculoskeletal disorders, which are common among massage therapists, can help you also understand these in your clients, so you can better choose the treatment techniques you use;
10. Learning to be good to yourself by taking care of your own health and career longevity will enhance your compassion for others – your clients will definitely benefit as a result.

How has learning about self-care and injury prevention made YOU a better therapist?  Let us know here.

Static loading, saltwater taffy, and tractioning: What could these three things possibly have to do with each other? I promise to tie them all together by the end of this blog post.

Static loading occurs when you hold an isometric muscle contraction. One example from massage work would be tractioning a client’s leg by grasping the foot and ankle and pulling. If you’re going to overcome your client’s stretch reflex, the period during which the muscle reacts to lengthening by contracting, then you would need to hold the traction for at least 30 seconds. This is when the static loading happens in your own arm muscles as they work to maintain your grip and the tension on the leg.

The problem with static loading is that the sustained muscle tension reduces blood flow to those muscles. So, at a time when the muscles are working hard, they’re not getting oxygen and nutrients, and metabolic by-products aren’t getting flushed out. As you can imagine, this lack of circulation can create fatigue, muscle soreness, and possibly contribute to musculoskeletal injury over time. Our muscles are a lot better off when they’re used in a dynamic, contract-and-relax pattern that helps pump the blood through them. The simplest example of this is walking, where the muscles of the legs and hips alternate contracting and releasing.

Saltwater taffy is a stretching program developed by Kay Rynerson, who practices massage and teaches continuing education in the Seattle area. It’s a form of dynamic stretching in which you hold the stretch just long enough to say “saltwater taffy” before releasing it. You repeat this stretch-and-relax movement several times to lengthen the tissues while at the same time warming them up. I like the visual imagery that comes with saying saltwater taffy. If you’ve ever seen a taffy pulling machine you know that it repeatedly pulls the taffy to help stretch it into a good consistency.

So, how do these concepts tie together? If dynamic stretching is an effective way of lengthening muscles, then can’t we apply the same concept to tractioning? Rather than using sustained tension when tractioning, and creating static loading in our own muscles, what if we used dynamic tractioning instead? The pull-and-release motion repeated several times could be just as effective at lengthening the client’s tissues, while at the same time allowing the practitioner to use a much healthier contract-and-relax pattern with their own muscles. Please leave a comment to share your thoughts and experiences.

Is anyone out there doing dynamic tractioning now? I’ve tried it a couple of times, particularly with the head and neck where it can be difficult to hold sustained tension. I’d be curious to hear about others impressions and experiences with different methods for tractioning.

You might think that, as one of the Save Your Hands bloggers, I would identify the repetitive motions of massage as the most significant injury risk that therapists face. But I think that the greatest hazard comes from a much less frequent, but potentially more injurious exposure, one that could cause injury even with a single exposure. That hazard is working with clients who require physical assistance when getting on and off of the treatment table.

Some therapists might go their entire careers never working with clients who need anything more than a steadying hand when getting off the table. Other therapists might specialize in working with the elderly or with clients who have special needs, and be confronted with this issue on an almost daily basis. In between might be therapists who work at a large spa or clinic with many clients, and the odds are that sooner or later one of those clients will need more than a little assistance.

So how much physical assistance is too much for the therapist to safely provide? A common guideline in healthcare is that no one caregiver should lift more than the equivalent of 35 pounds when helping a patient get to their feet, or move from a bed to a wheelchair. So if a patient weighs 140 pounds and has the leg strength to support half of their own body weight, then you would need two caregivers to help support the other 70 pounds. What about patients who can’t support any of their own weight, or who have balance issues and could fall at any time? More and more hospitals are using powered lift assist devices to help transfer these patients, protecting the safety of both the patient and the caregivers.

The question is – what is a good strategy for working with clients who need assistance in a spa, clinic, or small practice that doesn’t have the same resources that a hospital does? What about those situations where a client with special needs doesn’t communicate that ahead of time, leaving the therapist unprepared? It’s important that these clients have the same access to massage and bodywork as any other client. But how can our industry provide that care without placing therapists at risk for injury?

I’m hoping this blog can become a forum for sharing ideas and best practices for reducing injury risk. So, please share your experiences and ideas on this issue. How have you handled this situation in the past? Do you have a plan in place for assisting clients who need the help? What do you think we should be doing as an industry to address this issue? Please send a link to this blog to any others you think might be interested in helping out.

It’s great that therapists are trying new ways to do massage.  In online forums and social media, we see therapists talking about, for example, how using the knuckles instead of the fingertips is the most risk-free way to do massage.  Another swears by the forearms, and yet another by avoiding the upper extremity altogether and using the feet to do massage.

The reality is that each “tool” we use to do massage, be it hands, thumbs, knuckles, forearms, etc., has its own set of risk factors. Some have fewer risks than others.  Thumbs and fingertips are inherently unstable and therefore carry the most risk for most people: first, because their structures are inherently unstable, and their delicate ligaments, tendons and cartilage can be easily damaged; second, because the instability forces you to contract the forearm flexors and extensors quite a bit to keep them from buckling, and this increases pressure in the carpal tunnel (which can lead to CTS) and can cause tendonosis in the forearm muscles.

But there are risks associated with use of any part of the body to apply pressure. To use the knuckles (which aren’t all that stable, either, if you use only 2-3 of them), you have to stablize with the forearm flexors and extensors, too, and if you’re not stabilizing your scapulae at the same time and using the larger muscles of the shoulders and back to create the force, your shoulders can be at risk for injury. In our 2006 study of injury among massage therapists, shoulders were the body part most often injured. Same goes for use of the forearms – the shoulders are still vulnerable, although certainly the large, flat surface of the forearm offers much more stability than the fingers, thumbs or knuckles.  No matter what body part you use, transfering pressure through the bones of that body part causes wear and tear to the joints which can lead to osteoarthritis over time.

And as for using the feet: not only do they also have small bones and other soft tissues that can get injured, but you have to hang on with your hands and arms to overhead bars as you massage.  We recently had a CIPI candidate tell us that she was starting to have shoulder symptoms from hanging on to the bars, and I have heard of another therapist who  injured her feet by massaging with them.

So am I saying that it’s not good to look for alternatives to using the hands to do massage? No, it’s actually a really good idea to do that.  Just bear in mind that there is no one part of the body that is magically free of risk factors for injury. Being aware of the risks of using a particular body part to do massage is very important.  For choosing which body parts to use for your massage techniques, the approach that seems to work best involves frequently changing the part of the hand or arm (or even feet) you use to do massage, so that no one part becomes overused. Using real tools (IndexKnobber, Massage Star, etc.) when possible can also be very helpful.

Do you use a certain part of the body to do massage more than another? Share your experiences with us here.

Do you hate doing sit-ups or crunches? Then I have some good news for you. According to Stuart McGill, a professor of spine biomechanics at the University of Waterloo, you shouldn’t be doing them because they can be bad for your back. Sit-up and crunches create a lot of compressive force on the intervertebral discs in your lumbar spine. How much compressive force? As much as 3,350 newtons. If you’re not into the metric system, that more than 750 pounds of compression!

The U.S. National Institute for Occupational Safety and Health (NIOSH) recommends a limit of 3,400 newtons of compressive force to help protect your intervertebral discs. They acknowledge that even at that level up to 20% of the population might suffer a disc injury with repeated exposure.

How is it that an exercise that’s often recommended to strengthen your abdominals and protect your back turn out to be bad for your spine? Think about what a sit-up or crunch involves. You’re strongly contracting muscles that compress the spine while it’s in a flexed position. That’s the same type of exposure you would have if you were lifting something heavy from the floor by bending forward at the low back. That’s just the kind of thing we’re always telling people not to do.

You’re not off the hook for exercising though. It’s still important to maintain good core strength and endurance to help protect your back. What are some core exercises that won’t be so hard on your disks? Look for yoga and Pilates moves that you can do with your spine in neutral. Bridges, planks, “bird dogs”, and similar moves engage your core without requiring spinal flexion or really strong muscle contractions. And don’t worry about it if you aren’t seeing those “six-pack abs.” Genetics and body type have as much to do with having that “ripped” look as conditioning of the muscles does.