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

In my last post I wrote about the time it takes to master a skill, and how the average massage therapist isn’t in the profession long enough to truly reach that level. A few folks left some good comments about the factors that can shorter massage careers – mostly burn-out, injury, and lack of financial success.

All three factors are inter-related in a way. Striving for too much financial success too quickly can lead to burn-out and injury. The emotional strain that accompanies burn-out can lead to physical problems that can make injury more likely. And a serious injury comes with both emotional and financial consequences.

So what can we do as a profession to address these concerns and improve the longevity of therapists? I’d like to share my ideas on the subject starting with this post, and hopefully generate some discussion.

I believe that the solution begins with massage schools. Think back to when you were in massage school. If you were like me you didn’t know anything about massage. I had benefitted from receiving several good massages, and I’d given a few “back rubs,” but other than that I was pretty clueless. I looked to my instructors to teach me how to give a massage, and trusted them to teach me how to do it well. Fortunately, I went to a very good school that stressed working safely and being realistic in my business goals.

Students in massage school go there because they are ready to learn. That makes it the best time to teach them everything they need to become successful therapists, including how to take care of themselves. This needs to be part of the curriculum from the beginning, not a special “self care weekend.” Making self care a separate topic can create the impression that it’s a secondary consideration, a nice thing to do for yourself if you have the time.

Instead, instructors should incorporate concepts like good body mechanics and using less stressful techniques into the way they teach basic massage. The message should be: “This is the way massage work is done. We use our bodies to their best advantage, and we work within ourselves.” If there’s a student clinic, sessions can be scheduled to gradually increase the number of clients students see. The message here is: “Don’t try to do too much, too soon.”

This approach benefits the schools as well as the students. Most massage schools are already trying to fit in all of the required topics into the number of hours that students are willing to pay for. Asking them to teach self care as an additional topic would mean having to give up teaching something that may be equally as important. Integrating self care as core concept in a massage curriculum wouldn’t take up any more time, and should result in graduates who are better prepared for a long career in massage. And what better advertisement could there be for a massage school than having the most experienced and successful therapists practicing in the local area?

As always, your comments are welcome.

What New Year’s resolution will you make to keep your hands, shoulders, neck and back healthy as you massage in 2011?

Here’s one suggestion: resolve to stop looking down at your clients while you work. It’s really not necessary to stare down at your clients. Most therapists do this unconsciously, out of habit. Others are looking to see how the client’s tissues are reacting to the massage; this can be done with a glance, or by peripheral vision rather than staring.

There are two great benefits when you stop looking down as you work: first, you’ll have to rely more on your palpation skills, so you’ll develop those skills more; and second, you’ll allow your neck muscles to relax and stop putting so much stress on your cervical intervertebral discs (which can lead to osteoarthritis over time). Remember, your head weighs as much as a bowling ball (10-12 lbs.) – that’s an awful lot of weight to be hanging off of the delicate structures of your neck all day long, every day!

Let us know YOUR New Year’s resolution for self-care and injury prevention.

Best wishes for a Happy, HEALTHY New Year!

As I was grading our CIPI-Advanced Concepts in Ergonomics course the other day, I read an interesting comment about body mechanics. The comment was made by a working massage therapist who has studied body mechanics in-depth for a number of years, and has worked very hard to always use ideal body mechanics in his work. He said that even though he has great body mechanics and is hyper-vigilant about using them as he works, he had to admit that he still ends up in awkward postures sometimes.

I reassured the therapist that he shouldn’t feel bad, because he’s not alone. We all end up working in awkward postures at times, despite our best efforts to use great body mechanics. Why? Because no one can be hyper-vigilant every moment they’re working. As a therapist, your focus is mostly on your client and how they’re reacting to your treatment – it makes sense that a therapist would at times forget to monitor their own body’s reactions as they massage. This is the big limitation with body mechanics: no one uses good body mechanics all the time, because it’s really not humanly possible to do so.

You also may not be able to use good body mechanics if your workspace is designed in a way that prevents you from using good body mechanics. If you don’t have enough space around your table, for example, it will be impossible to place one foot behind the other to get an appropriate stance to use your body weight and your larger muscles to create movement and force.

Another limitation is that good body mechanics addresses only a few of the risk factors for work-related musculoskeletal disorders, like awkward posture and fatigue (factors related to the physical demands of your work), but doesn’t address the other important risk factors, for example, personal physical and emotional factors and the additional, cumulative effect of off-work risk exposures.

Since many different factors contribute to causing injury, you’re likely to be disappointed by the results if you count on only one injury prevention strategy (like using good body mechanics) to keep you healthy. For this reason, experience and research have shown that a multifaceted approach using a number of different strategies (including ergonomics, which involves fitting the work to the worker, instead of fitting the worker to the work as body mechanics does) is most effective in preventing work-related MSDs. Some of the other important strategies include avoiding overloading your work schedule, taking care of your general physical and emotional health, and treating symptoms early and effectively.

I’ve been reading the book Outliers by Malcolm Gladwell. The book is about people who are successful and the reasons why they’ve succeeded while others haven’t. One of the chapters is “The 10,000 Hour Rule.” Its title comes from the theory that it requires 10,000 hours of practice to really master a skill. Gladwell uses examples from sports, music and computer programming to illustrate the concept that large amounts of practice are necessary to take someone with potential and make them a success.

So, if it takes 10,000 hours to really get good at something, how long would it take for a therapist to do that much massage work? According to the 2009 AMTA Industry Fact Sheet, the average therapist does 19 hours of massage work per week. Working 50 weeks a year, it would take a therapist about 10-1/2 years to get in 10,000 hours of massage.

Unfortunately, that same AMTA Fact Sheet reports that the average therapist spends just 6.3 years in the profession. According to the 10,000 hour rule, most massage therapists are falling a few years short of becoming truly skilled at what they do. This isn’t to imply that less experienced therapists don’t give a good massage. I’ve received really excellent work from practitioners who are just out of massage school. But to really develop the type of skills that come from lots of experience, from working on a variety of conditions, and from hundreds of hours of continuing education, it probably does take 10 years in the profession.

So what do we need to do as a profession to make sure more therapists can reach that 10,000 hour mark? Are injury and burn-out ending massage careers too early? Are inexperienced therapists trying to get to that 10,000 hour point too quickly and paying the price? I’d love to hear what others think about this topic. Please add a comment if you have any ideas on the subject.

Be safe, be well. Rick

We all spend a great deal of time working with our arms in front of our bodies, often hunched forward. We type on the computer, wash the dishes, change the diapers, make dinner, etc., all in this position. Massage therapists and bodyworkers also work much of their time in this position. The result is often muscles that are shortened in the front of the body (especially the pecs and abs), stretched-out and weak in the thoracic (like the rhomboids), and tight in the upper thoracic/base of the neck (upper traps, levator scapula).

I’ve found two wonderful exercises to counteract this problem that I’ve started doing every day, and I’d like to share them with you. They use a product called the OPTP Pro-Roller-Soft (about $32), a tool that was recommended to me by a physical therapist (www.optp.com – I’m not affiliated with the company). It’s basically a solid foam cylinder that’s fairly firm but has some give to make it comfortable. If you feel any pain or discomfort as you do these exercises, stop doing them.

Exercise I: Lie down with your coccyx at the bottom of the roller and your head at the top. Let your arms fall straight out to the sides, perpendicular to your body, and bend your knees so your feet are flat on the floor to let your low back relax against the roller as much as possible. You’ll probably notice that your low back (lumbar spine) doesn’t lie completely flat against the roller at the beginning. As you balance on the roller, raise one foot about 6 inches, then place it down and raise the other foot – keep going as though you were marching in place, alternating feet. This works your abs, and you will probably also notice that after you’ve done this for a few minutes, your low back will lie flatter against the roller. Also, your arms will gradually lie flatter against the floor – at that point, you can try to move them along the floor toward your head as far as you can go, to get a greater stretch through the chest and back.

Exercise II: sit on the floor with the roller horizontal behind you. Clasp your hands behind your head with your elbows out to the side (this is to support your head – don’t pull forward on your neck). Lean back on the roller, lifting your butt slowly off the floor, and start rolling back and forth on it, which will give you a nice, fairly deep massage. You can roll on your lower thoracic/upper lumbar spine, then work up to the top of the thoracic spine. Then roll to where the roller is just below your shoulder blades, and lean your shoulders and head back (still supporting your neck with your hands) to get a good stretch through the entire front of your body.

When you get up after doing these two exercises, your posture will be much improved, and your chest will feel lifted and open. Your upper back and neck muscles should also feel more relaxed. Keep your roller at work with you, and do these exercises (which take only two or three minutes) on your break between massages!

Let us know how these exercises work for you. If you have any other exercises that you find really help counteract the effects of your massage work, please post them here.

Looking at the equipment a massage therapist uses daily in their work and making sure it fits their body well is an important part of ergonomics, one of the key elements in any injury prevention strategy.

One piece of equipment you probably use quite a bit is a computer. It may not be the piece of equipment you most associate with massage work, but it’s important to look at your computer workstation and make sure it’s set up in a way that minimizes your exposure to risk factors for injury.

Typing on the computer exposes your upper extremity to several risk factors, including repetitive motion (from typing and mousing) and possibly awkward postures. It’s easy to get into a forward-head posture and to “slump” while you work at the computer, and both of these postures create stress for the neck and shoulders. Your neck, back, shoulders and upper extremities may already be overused in your massage work, so you want to make sure you’re not adding to the stress on your body with a computer workstation that is poorly set up.

Ergonomics always seeks to fit the work to the worker, rather than fitting the worker to the work. In the case of working at the computer, you could try to sit up straighter, not crane your neck or keep your wrists as straight as possible; however, if your workstation is set up in such a way that it’s very difficult for you to change your body mechanics, you’re going to be fighting a losing battle. It’s much better to adjust the workstation to better fit your body, making it easier for you to sit in a more neutral posture and keep your wrists straight.

There are a number of good web pages that discuss the ergonomics of one’s computer workstation. Here are some suggestions (links below). You can also find a discussion of this topic and a detailed workstation diagram in the Appendices of Save Your Hands! 2nd Edition:
OSHA e-tool
HealthyComputing.com
UCLA’s 4-Step Guidelines
Laptop tips

I spent this past weekend exhibiting at the Florida State Massage Therapy Association conference. I spent each day on my feet, greeting massage students and professionals and chatting about their self-care and injury prevention efforts and concerns. I rarely got a chance to sit down, and when I wasn’t standing in place, I was taking small steps in and around the booth. At the end of each day I was very tired. After two and half days, I felt stiff all over, my back hurt, my legs hurt, and I was physically exhausted.

You might be wondering why someone who is relatively young and in good shape would find just standing around so tiring. It’s actually quite fatiguing to stand in one place or take only small steps for long periods. My muscles were being asked to maintain a fairly constant level of contraction to hold me up and in place, and that was keeping them in a state of static loading with not enough oxygen getting into my tissues. The result was stiffness and pain when I finally did start moving again, and an overall level of fatigue. With my muscles so stiff and fatigued, I could easily have injured myself if I attempted to do more strenuous work, like lifting boxes of books and carrying them to my car.

Now think about doing massage work. Many therapists stand for most if not all of their massage. They may take very short breaks, if any, between massages, and may not sit at all for hours on end. While they’re massaging, they may plant their feet in one place for a good portion of the massage. They may spend a good portion of the massage with their back bent over the client. The result? Fatigued, stiff, contracted muscles that could tear if an additional demand were placed on them, for example, reaching out farther than usual or lifting the client’s limb.

To avoid fatigue, be sure to sit down for at least a portion of your massage. A good rule of thumb would spending 15 minutes of every hour seated. Be sure to move around as you work – don’t let yourself stand in one place for too long. Every few minutes, try to move to a different position at the table. In the 17 years that I’ve observed massage therapists working, I’ve found that the massage therapists who have the fewest issues with symptoms or injury are those that are in nearly constant, fluid movement as they work. Try to incorporate movement into your massages, and be sure to take enough of a break between massages to sit down, relax, breath and prepare for the next client. Your feet, legs and back will thank you!

I crashed my bicycle the other day. Wait. Let me back up and introduce myself. I’m Rick Goggins and I’ve worked with Lauriann Greene spreading the word about injury prevention for massage therapists for several years now. But even when your job is injury prevention, you can still get hurt.

Getting back to my crash, it was a pretty embarrassing event for an experienced cyclist. A moment’s inattention, a mailbox that stuck out into the bike lane, and I found myself laying on the pavement. I wasn’t going very fast, but asphalt is just as hard at 10 mph as it is at 20.

Fortunately I was wearing padded cycling gloves. They literally saved my hands. Instead of scraped up palms or a broken wrist, I just had a bad bruise across the thenar muscles at the base of my thumb.

My crash makes for a good reminder to protect your hands outside of work. Gloves are a good idea when gardening, doing home improvement projects, and cleaning around the house, as well as for recreational activities.

My injury also reminded me just how much we use our thumbs over the course of the day. Turning a doorknob, grabbing the handle of my computer case, even hitting the space bar on my keyboard were all quite painful until that bruise healed. So take care of your thumbs, and they’ll take care of you.

Be safe, be well. Rick

I’ve been struck recently by the increasingly frequent practice in the massage profession of doing longer and longer massage sessions. While 50 minute (spa setting) or 1 hour massage are still the norm, more and more therapists are now regularly doing 1 1/2 hour, 2 hour or even 3 hour massages. Sometimes they are asked by an employer to do this, but many times they are willing to do these long sessions in their own private practice.

I find this practice troubling from an injury prevention point of view. To prevent injury, the body needs periods of rest and recovery, so that microtrauma caused by repetitive motion and other risk factor exposures can heal. Repeated trauma without adequate healing time can lead to injury. Fatigue is also a risk factor for injury, and who would not be fatigued by doing a 2-3 hour massage, particularly during a day when you’re also doing other massages?

I also find it troubling because I don’t think it’s beneficial to the client. I just had a great 1-hour massage today, and I felt very relaxed afterward and in less pain. Frankly, I don’t think I would have felt much more relaxed or in that much less pain if it had lasted longer – maybe 10-20% more, if that. So I think that therapists (and clients) overestimate how much better they would feel with a longer massage, and end up tiring themselves and increasing their injury risk for very little additional gain, if any. Since some of the massage involved working on painful areas, and I already felt sore 6 hours later due to the work that had been done there, if more work had been done, it would have been too much and I would have felt too sore. I have had 1 1/2 hour massages, and I remember feeling nauseous and really groggy afterward. That’s not how I want to feel after a massage.

Clients need time to integrate the work you do, to gauge how their bodies feel different, to see if the work was helpful, etc. That comes from having a series of massages to work on their various issues. Therapists need to educate their clients and explain that you get better results from a series of massage than from one long massage. Chiropractors, physical therapists and other manual therapists work in this way – they create a treatment plan involving a number of sessions. It’s just not possible to work on everything in one massage, and the result is over treatment and an exhausted therapist. It’s part of setting healthy boundaries to say “no” to really long sessions. It’s also better for your business, as you will encourage the client to think of you as her ongoing therapist that she sees regularly, rather than someone she sees once and maybe never again. OK, maybe you could do a 1 1/2 hour massage under some circumstances, but not on a regular basis. And I just don’t see any justification at all for 2 hours or longer, not from a therapeutic point of view and certainly not from the point of view of maintaining your own health and career longevity.

Rick and I are very happy to collaborate with our friends at Massage Magazine on our new blog.  Back in 1999, Massage Magazine was the first to publish a regular column on self-care and injury prevention, written by myself, called “Helping the Healers”.  So I was really pleased when Massage Magazine once again asked me to provide regular content on this important subject, this time in blog format. Rick Goggins will be blogging with me, contributing his wisdom and knowledge as both a Licensed Massage Practitioner and a Board-Certified Professional Ergonomist with nearly 20 years of workplace injury prevention and ergonomics experience.

In this blog, we’ll be looking at all aspects of self-care, injury prevention, body mechanics and ergonomics for massage therapists. Preventing injury on the job was a major concern for massage therapists back in 1999, and it still is.  In 2006, Rick and I did a study that produced the first reliable statistics on symptoms and injury among American massage therapists, and the results showed that there is definitely reason for all massage therapists to seriously address this issue.  We found that 77% of massage therapists experience symptoms or injury as a result of their work. While that’s a worrisome number, Rick and I also want you to know that there is a great deal you can do to prevent injury.  Injury is common among massage therapists, but it’s definitely not inevitable.

So what do you have to do to prevent injury due to your massage work?  I wish I could tell you “just use good body mechanics”, or “never do more than X number of massages per week.”  But it takes a bit more effort than that.  We tend to want to find one strategy, one simple technique adjustment or new approach to body mechanics that will keep us injury-free throughout our careers.  But there really is no single approach that has been shown to be effective. To maintain your general health, you have to use a number of tactics (eat right, exercise, etc.) – the same is true to avoid work-related injury.  Since there are many reasons that therapists become injured, you need to use a number of different tactics to address the different reasons (referred to as “risk factors”).  For this reason, research has shown that the most effective approach to injury prevention is multifaceted and holistic.  This is the approach we’ll be talking about extensively in this blog.

In this blog, Rick and I also hope to relate some of the science that exists to help you protect and prolong your career.  There are decades worth of research on this subject that has produced proven methods that we know are effective.  You can use these methods not only to prevent injury in your own career, but also to better understand and treat your clients’ work-related symptoms and injuries.  After all, most of your clients work, and they’re also exposed to risk factors, both physical and emotional, on the job.  So you’ll not only learn to save your own hands, neck, shoulders and back; you’ll also enhance your skill as a therapist by learning more about preventing injury!

We look forward to reading and responding to your comments and questions, so please let us hear from you!