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

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.

Fatigue is a risk factor for injury, so it’s important to avoid working to the point of fatigue.  You’ll need to adjust your ergonomics and body mechanics to avoid fatigue, but you’ll also need to develop awareness of when you start to feel fatigued or your energy level is low.  When you notice that your energy is fading, it’s important to take action to rev up your energy and refresh yourself.

Here are 10 great ways to increase your energy and keep you going throughout your work day:

1. Go for a walk: even a 5 minute walk gets your circulation going, refreshes you by getting you out of your work environment and exposes you to the beauty and fresh air of the outdoors. Hopefully you can walk somewhere in a natural surrounding, but even if you’re in a city, you can still feel more energized after a walk.
2. Refresh yourself with cool water: put some lemon or cucumber slices into a spray bottle, and put the bottle into the fridge.  At your break, spray your face, then spray some of the water onto a soft cloth and wipe the back of your neck and arms.  You’ll feel instantly refreshed!
3. Take a power nap: if you feel really tire, for example, if you didn’t sleep well the night before, it may be helpful to lie down in a quiet place for 15-20 minutes.  A short nap can be all you need to get your energy going again, but be sure to sleep no more than 20 minutes, otherwise you may feel groggy afterward.
4. Eat an energy snack: studies show that combining a bit of protein with fiber and a little fat can give you an energy boost. Try peanut butter on a whole-wheat cracker, or some yogurt with a handful of nuts.
5. Hydrate: dehydration is one of the leading causes of fatigue.  Be sure to drink throughout the day, and make it water, which hydrates better than soft drinks, coffee or tea.
6. Get enough sleep: this seems obvious, yet some people don’t make the connection between lack of energy at work and lack of sleep at night.  Most people need 7-8 hours of restful sleep per night to be at their best during the day.
7. Don’t skip breakfast: your body needs fuel after fasting all night.  Studies show that people who eat a good breakfast have more energy throughout the day.  A breakfast including whole grains, a little protein and some fruit should keep you feeling perky.
8. Breath in, breath out: take 5 minutes to breath deeply and you’ll find that you feel refreshed afterward.
9. Use aromatherapy: certain essential oils are known for their stimulating, energy-inducing qualities.  Try peppermint, basil, rosemary, or tea tree oil to stimulate your senses and awaken your mind.
10. Destress: stress can deplete your energy and make you feel fatigued. Some great ways to reduce stress are to exercise, talk to a good friend, meditate, pray, or pet a dog or cat. Developing awareness of your stress level throughout the day and taking action to relieve that stress will give you more energy.

I’ll even give you an 11th tip: EXERCISE!  People who exercise regularly have more energy than people who are inactive. Since staying in good physical condition is also important for preventing injury as a massage therapist, you now have yet another reason to get into a good physical conditioning program!

What do YOU do to keep your energy high throughout the day?  Please share it with us here!

This may be a new word for most of you: Thumbstitute.

OK, it’s a silly word, but it’s an important concept for massage therapists. Finding something other than your thumbs to perform your work just might prevent an injury down the road. Thumbs are one of the most frequently injured parts of a therapist’s body, and overuse is the most likely reason for this.

Consider this biomechanical tidbit – for every pound of force you apply with the tip of your thumb, you experience 10 to 12 pounds of force in the CMC joint at the base of your thumb. The pressure you apply to a trigger point might be 7 or 8 pounds of force, which could mean close to 100 pounds of force concentrated at your CMC joint. Over time that amount of force can damage cartilage and ligaments, resulting in joint laxity and osteoarthritis. Definitely something that we should all try to avoid.

So what’s your thumbstitute? Please share your favorite way to save your thumbs with the rest of us.

Maintaining good physical conditioning is very important as part of your personal injury prevention strategy. Strengthening exercises and stretches should be part of your conditioning program, but not all exercises and stretches are appropriate for massage therapists to do.

For most massage therapists, the hands and arms are overtaxed by their work. So as a general rule, you’ll want to avoid any exercises that:
• Place a great deal of pressure on the hands, wrists or forearms
• Require repetitive movements using the hand, wrist or forearm muscles
• Put your hands or wrists into awkward postures

A great example is push-ups. Push-ups are a great core strengthening exercise. But when you do a push-up, the weight of your upper body is supported by your hands. When there are so many other great core strengthening exercises you can do, why put so much stress on your already overused hands and wrists? Try a plank instead. You can do the plank on your forearms, which form a broad, flat surface that is much less likely to be injured by the weight of your upper body.

What about the exercise where you hold a small weight in your hand and do wrist curls (either in flexion or extension)? This is a good exercise for therapists who are just starting out, to help them develop strength in the forearm flexors/extensors. But for therapists who have already been working for some time, it’s just too much repetitive movement on top of the repetitive movements you already do all day long with your hands as you massage.

You’ll also want to make sure you keep your wrists as straight as possible with any exercise you do. Your muscles work best with your wrists in this neutral posture; flexing, extending or deviating them more than 10-15° reduces your strength and can lead to injury.

Remember to also be careful with your back, neck and shoulders as you exercise and stretch. These are also overused in massage work and can be easily injured by exercises or stretches that are too strenuous for these vulnerable body parts.

There is no such thing as neutral posture for the neck. There, I said it. After years of joining ergonomists, physical therapists and others in describing neutral neck posture, I’ve decided it doesn’t really exist. If we look at the concepts of neutral posture perhaps you’ll see why I’ve come to believe this.

One of things we most often hear about neutral posture is that the parts of the body are balanced over one another – ears over shoulders over hips over knees over ankles. Gravity pulls down on us, and we withstand it by “stacking our joints” one over another. This makes perfect sense and works well for most of the joints. But the center of gravity for the head, it’s “balance point,” is a little bit in front of the center of the skull. This means that we would have to tip our heads slightly back, looking up instead of straight ahead.

If you try holding your head in this position for any amount of time, you’ll find that it becomes very uncomfortable for your sub-occipital muscles. This is because tipping your head back breaks one of the other rules of neutral posture – muscles should be at their “resting length.” For most muscles, this is the mid-range of motion for the joint or joints that they cross. Shorten or lengthen a muscle too much, and you place it under tension and potentially reduce blood flow to it.

Another rule of neutral posture is to position a joint so that the larger muscles bear any of the load that the joints aren’t carrying. In the case of the human head, you’re talking about a 10 to 12 pound object on top of a very mobile portion of the spine. That’s a lot of weight for any one group of neck muscles to hold up.

Certainly there are postures that are worse for our neck than others. In addition to tipping your head back, tipping it forward more than 45 degrees for long periods of time can result in neck injury. So can holding it twisted to the side or tipped to one side, a position that some people get into when cradling the phone between their ear and shoulder. Forward head posture, where the head translates forward

The problem is that keeping your head in a “good posture” – head level or tipped slightly downward, looking straight ahead, ears over shoulders – doesn’t necessarily prevent neck strain if you hold it long enough without moving. Just think about any of your clients who spend a lot of time working at the computer. They probably spend a good portion of the day looking at the monitor, and where the eyes go, so goes the head. How many of those clients have tight muscles in their necks, likely due to holding their head in position for long periods of time.

There’s a saying in ergonomics: “The best posture is the next posture.” Of all the parts of the body, I think this applies most to the head and neck. The best advice I can give is to avoid any of the “bad postures” and keep shifting your gaze to keep your head and neck moving. Look at your client to assess the area you’re going to work on, but don’t look down continuously as you work. Trust your hands to “see” what’s going on with their tissues and give your eyes, and neck, a break.