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

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.

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!

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.

Anyone who provides care to another person faces the challenge of finding a balance between providing that care and taking care of themselves. This is true whether you’re a mother, a caretaker for someone who is ill, a healthcare professional who provides care to patients or a massage therapist who provides treatment (relaxation or otherwise) to clients.

It’s common for people who provide care to feel that they want to “give their all”, to make a truly substantial effort for others. This is natural: we all want to do our best, we care about others and we want to provide great care. The needier the person receiving the care, the more we feel we need to give, to respond to that need. In a professional situation, we also feel a pressure to perform, so the client will return to us for another massage, or to satisfy the demands of our employer, who may require us to “give it everything we’ve got.”

In addition, professionals who provide care tend to concentrate all of their attention on their patient or client. They are on the lookout for the client’s reactions, so they can tell if the treatment is effective. So they tend to shut out anything that may distract them during the treatment, including their own reactions, both physical and emotional.

All of this is natural and occurs very often in these types of relationships. The problem is that while it’s very rewarding in many ways to provide care, it can also be taxing and tiring, both physically and emotionally. If we become too taxed or tired, injury can occur.

For this reason, much has been written recently about the need for caretakers of all kinds to take breaks from caretaking, to address their own needs, and to receive support so they don’t get overwhelmed by the stress of the care they provide. It’s important for massage therapists to realize that they give quite a lot of themselves in their work, and to find ways to replenish their energy and refresh their spirits so they don’t end up feeling “burned out” by their work.

It’s also important to retain some amount of focus and energy for yourself during a massage. It’s usually not necessary to “give everything you’ve got” to give a great massage, nor to be so focused on the client that you lose all awareness of your body mechanics or ergonomics. A symptom of losing awareness is losing track of the time. In my experience, therapists who tend to go over an hour because they’ve “lost track of the time” are usually those who have lost their self-awareness and want to give so much that they are no longer setting limits. This is different than planning on doing a massage that lasts longer than an hour, which is a conscious decision.

It’s ultimately not healthy to be totally concentrated on your client and to give your all at all times. It’s not healthy for you, and eventually, it can have a negative impact on the client-therapist relationship. Hurting yourself to help someone else is contrary to the spirit of a therapeutic relationship, and it doesn’t help anyone, neither you nor your client.

It is absolutely possible to provide great treatment, be totally present for the client, and also be there for yourself and stay aware of your own needs. In fact, the only way to have healthy relationships of any kind is to be able to balance your own needs with the needs of the person you’re with, so you remain centered and whole as a person.

Be good to yourself – you deserve as much consideration as any of your clients do. By taking care of your own health (including preventing work-related injury), you’ll ensure that you’ll be able to continue providing great treatments to your clients for years to come.

Most of us have heard about the importance of strengthening your “core”. But what exactly does that mean, and why is core strength important for massage therapists in their efforts to prevent injury?

When we talk about the “core” in terms of preventing injury, we’re referring to the deep muscles of the trunk that stabilize the spine. Many people who have back pain have weak core muscles (including transversus abdominis and other abdominal muscles, the deep spine extensors, etc.). Since manual therapists have increased rates of back pain and injury due to the demands of their work, it makes sense to strengthen the core muscles to provide great stability to the spine and make it more resistant to injury.

In addition, the core muscles play a role in balance and the feeling of being grounded and centered. You need good balance to use proper body mechanics as you work, and your body mechanics will be better if you have a firm sensation of connection to the ground and are aware of your center of gravity as you work. Core strengthening can help with this.

Finally, strong core muscles help create better posture. Manual therapists tend to get into forward head and neck postures, in part due to a lack of core strength. With better general posture, it’s easier to find a neutral working posture and work within a range of near-neutral postures which allow you to use your body efficiently and effectively as you work.

The classic core strengthening exercise is the “plank”. This exercise works nearly all of the core muscles at once, and is simple to do. Lie on your stomach on a foam mat. Lift yourself up onto your forearms and toes (if it’s too difficult to be on your toes, you can be on your knees instead). Your forearms should be parallel to each other, and your elbows should be right under your shoulders Your back, neck and head should be aligned and flat/neutral (neither flexed nor extended) – look straight down at your hands. Tighten your abdominal muscles. Hold this position for 30 seconds, then relax and return to lying on your stomach. Do another two repetitions. Work up to 45 seconds, then 1 minute. Make sure you keep breathing normally throughout.

For an additional challenge, do the plank with your legs on a large, Swedish exercise ball. You’ll have to further engage your deep core muscles to keep your balance on the ball!

There are many great core strengthening exercises. Give them a try, and in time you’ll see a difference in the ease of your body mechanics. Your back will thank you!

Is there a core strengthening exercise that you particularly like? Write a comment and share it with other therapists here.

PLEASE NOTE: consult a primary healthcare practitioner before starting any exercise regimen.

I’d like to comment on an article on lifting in the March/April issue of Massage & Bodywork. The author’s thesis for the article is that by simply using good body mechanics while lifting (and holding a body part suspended), the practitioner can avoid injury. Research tells us that this is not true. While using good body mechanics will help the practitioner lift more efficiently, she will also need strength to be able to lift a heavy body part; you would certainly need a good deal of strength to also hold the body part suspended as discussed in the article. Even if the therapist is strong enough to lift a body part (the leg, for example, can weight 9-15 pounds), doing so places stress on her already heavily-used upper extremities, as well as on the low back. Holding the limb suspended would cause static loading, another risk factor for injury. Remember that the work therapists do has a cumulative effect: lifting a leg one time may not cause injury, but lifting a number of times a day or week over time, even with good body mechanics, has been documented to cause injury.

We would offer a greater service to therapists by pointing out that 1) lifting is a risk factor for injury, and one of the most common causes of occupational injury, particularly among health care workers; 2) the duration, frequency and intensity of lifting, as well as the presence of other risk factors at the same time, play a critical role in whether one gets injured or not; and 2) in the interest of preventing injury, lifting can and should be avoided as much as possible in massage work. Lifting the client’s leg as the author shows in the article (for example, for draping, or to do a stretch) could easily be accomplished by simply pushing the client’s foot along the table to flex the knee, then pushing the leg up and over the hip joint, rather than lifting the entire leg at once. Yet the author does not offer this simple alternative in her article. Developing awareness of risk and then finding alternatives for stressful techniques, in addition to using good body mechanics, has been shown in research to be much more effective than using good body mechanics alone. To help therapists effectively prevent injury, we need to provide a more complete, evidence-based view of this important subject.

By using a power-adjustable table, therapists can quickly and easily change their position in relation to the client/patient to enable them to use good body mechanics as they work. Yet many therapists still use stationary tables instead, often because they cannot or don’t want to pay the higher purchase price of a power-adjustable table.

A new government income tax credit may make purchasing a power-adjustable table much more affordable for manual therapists, including massage therapists. The law states that if you buy a power-adjustable table that goes down low enough to improve ease of access for someone who is mobility-impaired, you can apply for a tax credit for a little under 50% of the cost.

With tax season coming up shortly, we encourage you to ask your accountant or tax preparer about this tax credit and see if you can benefit from the tax savings. Investing in a power-adjustable table can make an important difference in your ability to prevent injury and enjoy a long, healthy career – be sure to take advantage of this great opportunity!

Here is the text of Section 44 of the Disabilities Act:

1338 DISABLED ACCESS CREDIT: An eligible small business is entitled to a non-refundable disabled access income tax credit for expenditures incurred to make a business accessible to disabled individuals (CODE SECTION 44). The amount of the credit is equal to 50% of the amount of eligible access expenditures for a year that exceeds $250.00 but does not exceed $10,250.00.

An eligible small business is any person that elects to claim the disabled access credit and that either (1) had gross receipts (less returns and allowances) for the preceding tax year that did not exceed $1 million, or (2) had not more than 30 employees during the proceeding tax year.

The disabled tax credit is computed on Form 8826 (DISABLED TAX CREDIT) and is claimed as one of the components on the general business credit.

Part 1 of this series of posts argued that massage schools need to incorporate self care into the way they teach massage. But what can be done to help those of us who have already graduated? The next logical step might be for all of us, as individuals and as an industry, to give ourselves permission to focus on taking care of ourselves.

By taking care of ourselves, I don’t mean just more body mechanics, stretching and exercise, or receiving massage (although these are all good things). I’m talking about focusing on our well-being even while working with a client.

One thing that schools do seem to teach well is a strong focus on the client when doing massage work. This focus is crucial, both to providing a massage that meets the client’s needs, and to avoiding any discomfort or injury to the client. But too often this client focus isn’t balanced by practitioner self-awareness. The result can be poor body mechanics, fatigue, burn-out, and even overuse injury.

Is it really in our clients’ best interest to focus on them to the point of forgetting about ourselves?  If we give too much to our clients early in our careers, don’t we run the risk of not having anything left to give to clients later on? Is it possible to focus both on ourselves and on our clients while we work, or is this somehow unfair to our clients?

I’m curious to know what others think about this. Please leave a comment with your thoughts. Thanks, Rick

As massage therapists, you obviously understand the value of massage. But how often do you take the time to get a massage yourself? If it’s not at least once a month, then you’re missing out on an important self-care practice that could help you stay healthy and reduce your risk of injury.

We often talk to our clients about the benefits of massage as a preventive measure to reduce injury risk, and that’s as true for the practitioner as it is for the client. Among its many benefits, massage helps to reduce overall muscular tension, which can increase fatigue and ischemia in muscle tissues. It also reduces hypertonicity in specific mucles and increases circulation in the tissues. Massage has been proven to reduce stress and anxiety, both of which are risk factors for injury.

If you are beginning to experience symptoms as a result of your massage work, receiving massage can help with treatment. If your work has caused microtearing or inflammation in your tissues, massage can help remove waste products to help encourage healing. It can also help reduce muscle guarding and spasm due to injury. Relaxation massage can help reduce pain and restore a feeling of well-being that can diminish with injury

And so much more! Due to the strenuous nature of your work, exchanging massage with colleagues every week can help you eliminate accumulated muscle tension and remove metabolic byproducts of inflammation before it can impact you further. This is as true for students as it is for practicing professionals.

You can also perform self-massage in between receiving massage. Remember, though, that your hands are already overused as a result of your work, so try to use your forearms, or a ball, or another type of massage tool rather than repetitively gripping your own tissue with your hands.

How often do YOU get a massage? Let us know the benefits you experience from receiving massage, for preventing injury in your career and treating your own symptoms.