Other Massage articles

Injury Prevention for Massage Practitioners

by Lauriann Green

 Now the good news: there is a great deal you can do to protect yourself from injury related to your massage work.

     There is good news and bad news about doing massage.
     First, the bad news: massage is very hard on your hands and upper extremities. Except for those massage therapists who do mostly very light techniques requiring little to no pressure, most massage practitioners experience some kind of injury or pain syndrome at some point in their careers as a result of giving massages. In fact, anyone who works intensively with his or her hands, like cashiers, musicians or computer operators, is prone to upper extremity injury, since the intensity of this work is more than most bodies can take. The arms and hands, with their small muscles, bones and ligaments, just were not designed to withstand intense, repetitive work for extended periods of time.
     Now the good news: there is a great deal you can do to protect yourself from injury related to your massage work. There are many ways to prevent injury, from changing posture to adjusting massage technique to avoiding injury-provoking situations. At the root of all these tactics are three concepts that are key to injury prevention. The first is learning to think of yourself as an athlete. Just like a tennis or football player, you are doing intense, physical work that requires skill, strength and endurance. The massage ‘athlete’ uses her upper extremity (the complex of the hand, arm and shoulder girdle) extensively in her work, so that part of her body is most prone to injury.
     Like any athlete, the massage athlete needs to train, stay in good physical condition, and take herself out of the game when she is injured to allow time for healing. She must also stay aware of her own body, since it is her tool for doing her job. Body awareness, the second key concept, is a consciousness of your body’s strengths and weaknesses, advantages and limitations, and a heightened attentiveness to the signals your body sends you as you work. Awareness keeps you in tune with your body, so you can respond promptly to symptoms and keep yourself from becoming injured.
     The third key concept is knowledge. You must have adequate knowledge of the physiology of injury to be able to recognize the symptoms of injury, and understand what it will take to treat those symptoms. Understanding how and why massage therapists get injured will help you assess your own injury risk so you can take appropriate steps to protect yourself from injury.

Why Do Massage Therapists Get Injured?
     Injury happens when the body is stressed beyond its own limits. Repetitive motion is the primary aspect of massage work that causes this stress. No one part of the body is designed to do the same motion over and over for long periods of time without rest. Each body part, depending on its size and strength, has its own limit as to how many times it can move in a certain way before the movement becomes too strenuous and tissue damage starts to occur. The thumb, for example, has quite small muscles that are not built to withstand repetitive demands on their limited strength.
     Adding pressure to repetitive motion ups the stakes. Doing repetitive motion with your thumbs with pressure takes more strength, as the muscles work to keep the thumbs stable as they perform the repetitive work.
     If you keep your thumbs in alignment with the rest of the hand and arm, you will be able to create the pressure and possibly some of the repetitive motion by using the larger muscles of the rest of the upper extremity. If you take your thumbs out of alignment, you cut off the support of the upper extremity, and create additional stress to the delicate joints of the thumb. Lack of proper joint alignment while massaging can add to your injury risk.
     The massage therapist’s own body characteristics can make him more prone to injury. Lifestyle and general health factors, including age, previous injuries, diet and use of alcohol, cigarettes or drugs, will play a significant role in the therapist’s ability to withstand stress and heal from injury, as will his level of strength and aerobic fitness. A therapist with above normal range of motion in his finger, hand or arm joints will be more prone to injury, since it will be more difficult for this therapist to maintain aligned positioning in his work. Developing awareness of the degree to which you have these body characteristics will help you protect yourself from being injured.
     Unhealthy work situations can increase a massage therapist’s injury risk. Like any athlete, the therapist must train in order to become physically capable of taking on increased amounts of physical activity. Suddenly increasing the number of massages you do without training to attain that level slowly is likely to provoke injury. Similarly, suddenly decreasing the time you take between massages can also put you at risk. You need enough time to stretch, breathe and relax between massages to allow your muscles to relax and to avoid the static tension that can cause injury. Massaging in a cramped room or with your table at an uncomfortable height will likely cause you to adopt awkward or stressful postures and positions as you massage, distorting your body mechanics.
     Your expectations concerning massage can also get you into trouble. Massage therapists have traditionally suffered silently with pain and injury, convinced that this suffering comes with the profession and must simply be tolerated. They may also believe in the concept of ‘no pain, no gain’, which we now know is totally false. Pain is never normal, and no massage therapist should accept pain as part of their massage work. Other therapists believe that there is a ‘right’ and a ‘wrong’ way to do massage. This attitude leads them to continue to do techniques that hurt them in the belief that these techniques constitute the ‘right’ way to work. To prevent injury, follow the axiom ‘if it hurts, don’t do it.’ It is essential to give yourself permission to say ‘no’ to anything that may cause you to be injured. There is no such thing as a ‘good’ massage and a ‘bad’ massage. Massage is an art as well as a science. Accepting that there is no one right or good way of doing it gives you the freedom to work with your body’s own strengths and weaknesses instead of against them, which will help you prevent injury.

Phalen's sign – test for Carpel Tunnel Syndrome (CTS). Hold the position for one minute; if pain or numbness and tingling are felt this is highly suggestive of CTS

Common Injuries Sustained by Massage Therapists
     Soft tissue injuries common to massage therapists fall into two categories: muscle/tendon injuries and nerve impingement injuries. The primary cause of these disorders is thought to be overuse, or using a part of the body beyond the point where it can function normally and remain healthy. These injuries are collectively referred to as repetitive strain or stress injuries (RSIs), cumulative trauma disorders (CTDs) or simply overuse syndromes. Left untreated or allowed to become chronic, these injuries can lead to osteoarthritis, and temporary or even permanent disability and the loss of function of the hands and/or arms.
     The most common muscle/tendon injury among massage practitioners is overuse syndrome. The most common injury sites are the thumb, the wrist, and the forearm. This chronic injury is characterized by gradual onset. Appearance of symptoms often occurs with a sudden and/or substantial increase in workload, or a sudden decrease in time spent between massages. Changing technique, trying new techniques, or even emotional stress can cause an onset of symptoms. The primary symptom of overuse syndrome is diffuse achiness, tightness and/or soreness in one part of the upper extremity rather than a sharp pain in one specific spot. Other symptoms include loss of function and paraesthesia. Classic signs of inflammation like swelling, redness and heat are generally not present in overuse syndrome. Overuse syndrome usually takes quite a while to resolve completely, often a number of years.
     Tendinitis and tenosynovitis are inflammatory conditions (of the tendon and tendon sheath respectively) that have a more sudden onset. These injuries are caused by tearing (strain) of tendon fibres or irritation to the tendon sheath. The clear presence of inflammation distinguishes these injuries from overuse syndrome. Among massage therapists, tendinitis and tenosynovitis are less frequent complaints than overuse syndrome. The main symptom is localized pain. The affected area is often swollen and hot. With proper treatment, and careful avoidance of reinjury, tendinitis and tenosynovitis tend to heal in a shorter period of time than overuse syndrome.
     Muscle/tendon injury as a result of doing massage is more common among massage therapists than nerve impingement injury. The two most common nerve impingement injuries sustained by massage practitioners are carpal tunnel syndrome (CTS) and thoracic outlet syndrome (TOS). CTS involves impingement of the median nerve at the carpal tunnel of the wrist. TOS refers to impingement of nerves C8-T1 at area of the base of the neck where the brachial plexus descends through the space between the first rib and the clavicle. Massaging in unnatural postures or with unaligned joints is often the cause of CTS or TOS. Like overuse syndrome, these injuries tend to develop slowly and can be triggered by a sudden increase in workload or decrease in time between massages.

Case Study: Lauriann G, Massage Student
     The author is a delicately built person with little to no natural strength or endurance, and was physically inactive prior to beginning a massage training programme. An overachiever, my anxiety about doing well in school translated into tension in my hands and arms as I massaged. Three months into an 11-month programme, I began to experience pain in the ulnar side of my wrist when massaging. I saw that other students were also in pain, and assumed this was a normal part of being a massage therapist that would go away as I developed more strength. In the ninth month of the programme, I enrolled in an externship programme in a local medical clinic. I had been doing two to three massage exchanges with other students per week. Suddenly, I was giving eight to ten massages per day, two days per week, with little break between massages. The pain, which had been fairly mild up to this point, became more intense, with stiffness and tightness in my hands and forearms. I knew I needed to stop doing so many massages, but the clinic receptionist had already scheduled appointments for me through to the end of my seven-week externship. I felt pressured to continue. By the end of the externship, I was in constant pain in both my wrists and arms. It was no longer only massage that produced the pain. Everything seemed to make my wrists hurt: opening a door, turning on a faucet; even brushing my teeth was painful. I finally saw a physician, who diagnosed my condition as a severe repetitive stress injury, probably overuse syndrome. The combination of lack of strength, lack of physical conditioning, and massaging with poor body mechanics (as most students do) with a great deal of tension had caused me to overstress and damage the tissues of my wrists.
     To treat my injury, I started a course of seven months of occupational and physical therapy. I was barely able to make it through to the end of my training programme, and get my licence; soon after, on the advice of my doctor and physical therapist, I completely stopped doing massage so my injury could heal. My massage career was over before it had begun.
     It took another year before my hands felt anywhere near normal again, and a total of three years before I was mostly pain-free. Now, six years later, doing any hand-intensive activity, like typing on a computer keyboard, can cause the pain to reappear, and I am still unable to give a massage without pain.

Injury Prevention Techniques
     From reading my case study, you can see the importance of preventing repetitive stress injury before it starts. Once you are injured, the road to recovery can be very long. Your massage career may be interrupted or even ended prematurely.
     These injury prevention techniques can help you save your hands, and your investment in your career:

• Get in shape: plan on working out at least three times a week, including strengthening, stretching and aerobics. Maintaining good circulation will help you heal any incipient injuries and keep them from developing into more serious ones;
• Develop good body mechanics: using your body efficiently to produce the most effective movement with the least effort will reduce the strain of your massage work on your body. Remain upright as much as possible as you work, keep your joints aligned in your hand and arm and use the larger muscles of the back and shoulder to create movement and your body weight to create pressure;
• Avoid other hand-intensive activities: there is only so much hand-intensive work one body can take. Playing an instrument professionally, or working as a computer typist in addition to your massage work will likely cause injury;
• Take care of your hands every day: they are the tools of your trade; treat them well. Avoid opening stuck jars, playing sports with your hands, hammering nails – anything that can cause trauma or stress your hands;
• Work with your body characteristics, not against them: if you have hypermobile thumbs, do not use them extensively in your massages. If you have a pre-existing upper extremity, back or neck injury, think about doing types of massage that don’t require strength or pressure;
• Vary your massage technique: use different parts of your hand and arms to do massage, to avoid repetitive motion to any one part. For example, use your elbow sometimes to create pressure rather than always using your thumbs;
• Don’t do massage techniques that cause you pain: stop doing any technique that causes you pain or discomfort – you have your choice of thousands of techniques that you can do without pain;
• Monitor your work habits: try to maintain a regular schedule of massages, so you don’t suddenly increase the number of massages you do or decrease the amount of time you have between massages. Experiment with table height until you find what works best for you; better yet, get an electric table that you can adjust as you work;
• Take time between massages: if you don’t have enough time between massages to relax, stretch, breathe AND change the sheets, you are putting yourself at risk of injury;
• Use other modalities in your massages: hydrotherapy, aromatherapy, energy balancing and spa treatments can attract new clients and add to the value of your massages. They will also cut down on the amount of intensive hands-on work you do in each massage, which will allow your hands to rest;
• Develop a realistic attitude towards your work: there are limits to what you can do for your patients. You are only human, with your own strengths and limitations. Respecting your own limits is healthy, and will help you keep your upper extremities healthy;
• Treat injuries immediately and effectively: at the first sign of pain or dysfunction, see a physician. If you are in pain, you are probably already injured. Letting it go on will only make it worse.

     Injury is a complex subject. There is no one magic formula that will keep you safe from injury. Improving body mechanics is essential, but even a therapist with excellent body mechanics can become injured. The most effective approach to injury prevention is multi-faceted, and takes into account the whole person you are, both in body and mind.