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

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.

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.

It’s been a while since I’ve posted here. Part of the reason for this was that I had to prepare for and teach a workshop on injury prevention for massage therapists. Which brings me to the topic of this post – how continuing education can help give massage therapists the skills they need to extend their careers.

Since I teach workshops specifically on injury prevention, you might expect me to say that everyone reading this should sign up for the next workshop they see that’s related to self care. But I understand that we all have limited time and money to devote to continuing education. Despite my own interest in self care, I have to admit that when I’m looking for continuing education, I’m more drawn to workshops where I’ll be learning new techniques.

It’s not like I think I know everything there is to know about self care already. I think that I could learn a lot by attending workshops taught by others on this topic. But there’s certainly an appeal to learning additional skills that can be used when treating clients. It’s also easier to cost justify a workshop when you might be able to attract new clients or charge a little more because of the new skills you’ve learned.

Even if you don’t take a workshop devoted to self care, there are still ways to use continuing education opportunities to help you avoid injury and prolong your career. You could learn new techniques like lymphatic drainage, cranio-sacral, or active isolated stretching that can be easier on your body as well as beneficial to your clients. You could also choose to learn treatment techniques that allow you to charge more per session, which in turn would allow you to work less and still have the same income.

I also believe that almost all continuing education classes in massage should incorporate some elements of self care into their curricula. This is similar to the idea I discussed in my first post of this series – that massage schools should integrate injury prevention and self care into the way they teach massage, rather than making it a separate topic. If all continuing education instructors focused on teaching ways to perform massage techniques that are safer for the practitioner, it would help those massage therapists who didn’t learn injury prevention in massage school.

I’d love to get some feedback on this concept. Any continuing education instructors out there who would care to comment? Has anyone taken a continuing education workshop where the instructor did a good job of demonstrating and reinforcing good body mechanics and injury prevention? Please let me know by leaving comment.

Thanks, Rick

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.

There’s been a push in the massage community recently to develop evidence-based treatment guidelines. This movement has the potential to benefit all of us, by giving us more clarity on which treatment methods are effective for specific conditions our clients may have. It will also help to give massage more recognition as a healthcare modality rather than a luxury. Establishing credible guidelines requires a considerable amount of research, which is both time-consuming and expensive.

I’d like to suggest that we should devote some portion of our research efforts and dollars on determining safe work practices for massage therapists. From some of the surveys that have been done, we already know that the majority of massage therapists experience musculoskeletal symptoms related to their work, and that a significant minority develop a diagnosed musculoskeletal injury. We know that massage work involves exposures to stressors such as awkward postures, repetitive motions, and high hand forces, all of which are associated with musculoskeletal injury.

We also have enough evidence to establish some rough guidelines around things like optimal table height and good body mechanics. But a lot of the larger questions about safe work practices remain. How many hours per week of hands-on massage work are “safe” for the practitioner – 20 hours? 30 hours? It’s likely to vary from person-to-person, but are there particular individual characteristics that can be identified that would tell us who should limit themselves to 20 hours and who can do 30 hours? And how much time should we leave between massages to allow for adequate rest and recovery? Should breaks be longer following a deep tissue session than after a relaxation massage session and if so, how much longer?

There are some research questions that relate both to safe work practices and efficacy of treatment. Does the use of hand tools provide both a deeper and more consistent application of pressure, as well as reducing physical demands on the practitioner, when compared to working with the fingers and thumbs?  Does applying continual pressure with the tips of the fingers and thumbs reduce the sensitivity of the nerves there, reducing our ability to detect trigger points and adhesions?

There are simple experiments that can tell us the answers to some of these smaller questions, and larger studies that can be done to help decide on the bigger questions of workload and career longevity. But first the massage community has to decide on this as a priority, and funding needs to be dedicated to conduct the studies.

I’d like to hear what others have to think about this? Would this be a worthwhile effort? What should be our priorities? What funding sources are there for studies such as these? Please leave a comment with your thoughts.

My last blog talked about the role that employers of massage therapists can have in helping to keep therapists well and extend their careers. But obviously employers can’t do this alone. Safety and health at work in any industry is a shared responsiblity between employers and employees.

An employer might put a lot of effort into creating an ergonomically-sound workplace, working with therapists to design treatment spaces, provide power-adjustable tables, and arrange schedules to avoid overloading therapists. But all of this would do little to prevent injuries if therapists don’t take the time to adjust the tables, ignore the principles of good body mechanics, or overload themselves by taking on a lot of massage work on the side.

Most massage therapists have a strong financial incentive to do a lot of massage work. After all, the more treatment sessions you do, the more money you make. There’s also often an economic incentive to take on more physically demanding clients, since many places charge more for deep tissue work.

Self-employed therapists have at least as strong a motivation to take on a very full schedule, if not more so. In addition to the economic realties of trying to make a living as a massage therapist, there may be another component. Therapists may judge their own success as a practitioner by how full their schedules are.

Less experienced therapists may be especially vulnerable to problems due to overloading. They may lack the endurance to handle the physical demands, or the knowledge gained from years of experience and continuing education that allows them to very their techniques and prevent overuse injuries.

Human beings as a rule don’t appear to do well with long-term planning and foreseeing the consequences of their actions. You can see the results of this in everything from global warming to the latest financial crisis. But this is our challenge as therapists, to think about our long-term careers in the profession, and not just about the here-and-now.

How do you set your schedules and decide on how much of a workload you take on? Please share your thoughts by leaving a comment.

I strongly believe that the best place for massage therapists to learn about ergonomics, body mechanics and self care is in massage school. But even if our schools graduate therapists who are prepared to work safely, this training still needs to be supported in the workplace. This holds true for massage therapists whether they work at a spa, for a chiropractor, at a massage clinic, or even if they work for themselves (sometimes especially if they work for themselves).

A therapist may know all of the principles of good body mechanics, but find herself unable to apply them when working in a treatment room that’s too small, or at a table that’s too wide or that does not adjust low enough. Or, a recent massage school graduate could find himself working for a chiropractor, trying to apply the principles of ergonomics to his work, but over-scheduled and risking early burn-out. Another recent graduate might decide to go into business for herself, but in a rush to build a client base, over-schedule herself and as a result develop an injury.

Employers of massage therapists control the conditions of work. They design and furnish the treatment rooms, set the schedules, and create the work expectations. The way in which they do these things can either create a healthy work environment, or one that contributes to fatigue, burn-out, and work-related injury.

Most employers rely on “standard industry practice” when they set the working conditions. They might schedule 10-minute breaks between treatments in a massage clinic, or have a lot of short, back-to-back treatment sessions in a chiropractic office. But is “standard industry practice” the right guideline to follow when we know that many massage therapists have musculoskeletal symptoms or injuries, and that career longevity is less than we would like?

I could post an entire series of blogs with recommendations for employers, everything from having enough open space around a massage table to allow good posture, to arranging schedules to avoid overloading therapists. But recommendations are better when they’re specific to the business, not just general guidelines.

Instead, I’m going to leave employers with one piece of advice: Talk to your massage therapists. Don’t just assume that everything is OK because they haven’t brought anything to your attention. Let them know that you are genuinely interested in their well-being, and that you want to work with them to make sure that they have good working conditions. What you learn may surprise you. And remember, happy therapists mean happy clients, so what you do to help your therapists will ultimately be good for business.