Injury Prevention for Massage Therapists
10- Year Retrospective
By Lauriann Greene
MASSAGE AND BODYWORK MAGAZINE
December 2005 marks the 10th anniversary of Save Your Hands!, my book on injury prevention for massage therapists. This anniversary would normally have no particular significance other than for me personally, if it were not for the fact that Save Your Hands! was one of the first comprehensive books about the risk and prevalence of occupation-related injury among massage therapy students and professionals and how to effectively deal with it. The large-scale release of the book throughout North America and its extensive promotion to massage schools, along with the self-care workshops I gave across the United States and Canada, gave this topic national attention for the first time. This was also a time when public awareness of repetitive stress injuries (RSIs) was increasing, due in part to the much-publicized lawsuits brought by injured computer operators against their employers in the early 1990s.
The problem of injury among massage therapists certainly existed long before 1995, and I was not the first to mention it. In the 1980s, Frances M. Tappen, in her book Healing Massage Techniques, wrote four brief, but important paragraphs about the incidence of work-related pain, arthritis of the fingers and wrists, and carpal tunnel syndrome among massage therapists.1 Maja Evans, in her 1992 release, The Ultimate Hand Book , wrote about burnout and injury among massage therapists. She claimed that “80 percent of the people who start out in bodywork drop out after the first two years,” due, among other factors, to their hands giving out and not possessing the physical stamina to do their work.2 It was evident that massage therapists were getting injured, but the cause and nature of those injuries had yet to be revealed.
How far have we come in these 10 years? How has the profession responded to the challenges of a changing massage industry? Do we know more about massage-related injury now than we did a decade ago? And, most importantly, have practitioners routinely incorporated self-care and injury prevention into their lives?
The Growth of an Industry
One of our major challenges has been the evolution of massage into a major industry. Once considered the domain of athletes or New-Age enthusiasts, massage has become mainstream and widely accepted, both for relaxation and for the treatment of musculoskeletal complaints. As a result, there is an increasing demand from the public for qualified massage therapists and a new opportunity within the medical community to integrate massage into standard allopathic treatment plans. Licensure requirements have been instituted in most states for massage practitioners, and an increasing number of insurance plans have agreed to reimburse for massage treatment. This period of time has seen massage change from a marginal activity to a mainstream profession, many of whose members can make a full-time living practicing massage. Thousands of new massage and bodywork schools have opened in North America and around the world, and the number of working massage therapists worldwide is now in the millions. While this evolution certainly represents a big step forward for massage therapists and bodyworkers, it also brings with it an increasing pressure on the practitioner to perform and produce at a high level. That expectation, in and of itself, greatly increases the risk of injury.
Even the massage techniques we use have changed. Insurance companies want to see measurable results before they will reimburse us for massage, and practitioners have to be able to justify their techniques. Broad, light techniques that emphasized circulation or relaxation have been, in many cases, largely replaced by techniques that work on specific areas of pain or discomfort with small, repetitive movements and pressure. Massage, which was historically a holistic discipline sought to bring a sense of well-being, increased circulation, and general relaxation to the body (rather than treat specific complaints), has become much more allopathic in its approach. Western consumers, who have always been more comfortable with an allopathic approach than a holistic one, also project those expectations to the massage practitioner and expect “treatment” and deep pressure during their massages. Unfortunately, it is those small, repetitive movements with deep pressure that put the practitioner at the highest risk for injury.
Massage in the 21st century is big business, estimated at more than $4 billion per year.3 The financial interests involved create an overall climate in the therapeutic workplace that is often hostile to the concept of self-care. Too often, there is a tendency to be more interested in the financial bottom line than in the health of the people who are doing the work. This was the case with large corporations that, in the 1980s and ’90s, chose to disregard the pain and dysfunction that was plaguing their employees who typed all day at poorly-designed workstations. Employees had to bring lawsuits against those corporations to convince them to start taking computer-related RSI seriously, upgrade workstations, and provide on-site education and consultation on workplace injury prevention.
A search for “carpal tunnel syndrome” on Amazon.com now brings up 3,288 books, and new ones come out every month. A more educated and informed workforce has been successful in putting pressure on corporations to install ergonomic workstations to enable their employees to work comfortably. These corporations have ultimately understood that it is in their own best interest to help their workers prevent injuries that could lead to workman’s compensation claims and work absences.
In the last 10 years, some massage clinics, spas, and even schools have chosen to pay more attention to their own financial interests than to protecting their students and practitioners from injury. Hundreds of massage therapy practitioners and students have written to me about their experiences. I have been disheartened to hear from many bodyworkers, even quite recently, who have been required to do a large number of massages each day with no more than five minutes break between them, often in cramped quarters unsuited to working in an ergonomic manner. I have also heard from a number of massage students and professionals that they learned little or nothing in school about injury physiology or injury prevention.
It is particularly worrisome to see there are still schools that do not deal openly with the risk of injury, even though there are many students who will experience pain and injury during their massage school training. Perhaps school owners feel including injury prevention in their curricula will alert potential students to the risk of injury in the profession and dissuade them from becoming massage therapists in the first place. It also appears some schools do not teach their instructors and administrators to take their students’ pain and other injury symptoms seriously and refer them out for appropriate treatment.
One student told me she was accepted into a massage school after revealing to the admissions officer that she was suffering from chronic elbow tendonitis and was told she shouldn’t worry about it because she would learn prevention techniques later on in school. She contacted me to ask my opinion before signing her enrollment papers. One can only wonder about a school that accepts a student who is already injured, without requiring she see a doctor and treat the injury before starting the program. The school officials seem more concerned about getting students to commit to their programs and pay their tuition than about protecting their health.
The massage and bodywork profession has played an important role in raising awareness of this issue within its own ranks. In the last 10 years, the major massage magazines have published many articles on injury prevention, written by myself and by other prominent people in the field. Workshops and seminars on the subject have been sponsored by the major massage associations at their annual conferences and independently. In the time since Save Your Hands! was published, several other books on injury prevention and self-care have come out, each bringing an additional point of view and helpful ideas to the discussion. While I don’t always agree with the thrust of these books or the specific advice offered in them, I am happy to see that other members of the profession feel injury prevention is an important enough subject to devote their time and effort to writing and publishing a book on the subject. These books help increase the visibility of this issue within the massage community.
While some of their counterparts have not, many massage schools have done their part to inform students of the risk of work-related injury by including injury prevention information in their curricula. Recommending a book on injury prevention sends a clear message that this is a key subject.
Schools that have instituted injury prevention curricula demonstrate a real concern for their students’ health on a human level. They also realize it is in their own best interest to keep their students healthy and to turn out graduates who are capable of sustaining viable, long-term careers in massage. This emphasis can only increase the stature of massage as a desirable profession and legitimize the school’s claim of offering potential students a meaningful and profitable career. If Maja Evans was right, and 80 percent of last year’s graduates will last no more than two years in their careers, then the future of the massage profession and the massage school business is not bright. In the future, schools will play a major role in determining whether the massage industry continues to grow or whether so many practitioners get injured that massage gets a bad rap as a “tissue” industry: Use them up, and throw them out.
While the increasing number of massage schools offering injury prevention curricula is a positive thing for the profession, I have concerns about a growing trend in schools (and in independent workshops) toward teaching “body mechanics” and touting it as the principal method of preventing massage-related injury. No one disputes the fact that it’s very important to learn how to effectively use your body as you perform massage and bodywork techniques. But learning body mechanics is not the same thing as learning injury prevention and self-care. It is the modern tendency to look for the “magic bullet,” the pill, treatment, or technique that will turn a complex problem into a simple one that can be dealt with quickly and easily.
Injury prevention is a complex subject with many facets: To effectively prevent injury, we must adjust technique, become aware of our own physical advantages and disadvantages, exercise, stretch, improve posture, understand the physiology and warning signs of injury, adjust our expectations and attitudes toward massage, be smart about managing our workplace and schedule, and practice good body mechanics (among other things). Poor body mechanics are not the only causes of injury, and good body mechanics are not the only elements needed to prevent injury. If using proper body mechanics prevented injury by itself, no top-level athlete would ever get injured, since those athletes perform their sports with nearly perfect body mechanics. And yet, nearly all athletes, even the best ones, get injured at one time or another. A massage therapist who never works out, has hypermobile wrists, suddenly increases the number of massages she does per week, and uses her thumbs 95 percent of the time she massages is likely to get injured, no matter how solid her body mechanics.
So indeed, this past decade has seen many positive changes in the injury prevention landscape. These changes have brought increased awareness of the risks of occupation-related injury to the public in general and massage and bodywork practitioners in particular, and a growing number of massage schools are including injury prevention information in their curricula. Certainly, then, massage therapists must be aware at this point that any hand-intensive activity can lead to repetitive stress injury, and the message has assuredly been passed within the profession that injury is a concern. And yet, many massage therapists continue to voluntarily do seven massages in a day with just enough time between them to change the sheets and continue to massage even though their hands are throbbing with pain.
What’s Going on Here?
I recently had an opportunity to reflect on this question when I taught an injury prevention workshop for a group of students and graduates of a massage school in upstate New York. I hadn’t given a workshop for about four years, and I was curious to see if massage therapists had become more savvy about injury prevention since my last contact with them. I always begin the workshop by asking if anyone in the group is experiencing pain as a result of their massage work. Usually, most of the participants raise their hands. Then I ask how many of those who raised their hands considered themselves to be injured. Before, I would invariably see most of the hands lower quickly, showing that participants were not anxious to admit they were injured, or that they didn’t associate their symptoms with injury. Four years later, the result was the same.
This experience shows me two things: First, there is still a good deal of shame and reluctance about admitting to injury as a massage therapist; and second, there is still a lack of understanding of injury physiology among massage therapists, evidence of a lack of education on the subject.
The Emotion of Injury
Shame and lack of education are linked. Shame is the reaction of those who don’t realize what they are suffering is common and widespread and who have been hounded by others who have no more understanding than they do. And yet, at this stage, how can therapists still remain in the dark on this subject? There has been considerable talk in the profession and elsewhere about this subject. All the anecdotal and empirical evidence, plus the data available on RSIs and occupation-related injury, lead us to conclude that massage-related injury is quite common among massage therapists, both students and professionals. I have seen hundreds of injured massage therapists in my workshops and heard from hundreds more. Their stories could easily be the same as thousands of other massage therapists: too little attention to their own bodies (an attitude that is epidemic in our society as a whole), too much demand to perform the most massages possible so they can make a living, too much pressure in the workplace and in school, and on and on.
The school administrators, instructors, and massage association leaders with whom I have spoken about this subject confirm these observations. A statistical study on the incidence of occupation-related injury among physical therapists4 recently showed that a significant percentage of those practitioners who use their hands less intensively and for shorter lengths of time in each session than massage therapists who do, experience upper extremity injury as a result of their work. In a world where anyone who works intensively with their hands is at high risk for upper extremity injury (computer operators, seamstresses, musicians, cashiers, etc.), why would massage therapists be exempt? And yet, many massage therapists still have a difficult time admitting the pain they’ve had in their hands for the past month is truly an injury and not “something that will go away if I just work through it.”
If massage therapists are ashamed to have symptoms of injury, that shame is going to keep them from getting the information they need to avoid injury and the treatment they need to be able to heal. There’s an inordinate amount of denial and intolerance among massage therapists and bodyworkers on this subject. I have been surprised to receive comments, even recently, from a number of professionals who illustrate this point. Like the one who has been working for 20 years with never an ache or a pain (in my opinion, a small minority) and found it ridiculous that anyone would be concerned enough about injury prevention to buy a book on the subject. Or the one who said he was well-informed about injury physiology and has never had an injury and, therefore, couldn’t understand why anyone would need “rudimentary” and “common sense” information about pain symptoms, inflammation, and injury.
After all this time, many massage therapists are still threatened by the idea of spreading information and education about injury and injury prevention within the profession. I continue to receive e-mails and letters from massage therapists who tell me they have been chastised or ridiculed by their coworkers or fellow students when they admitted to pain and injury. My personal experience with a massage-related injury that cut short my own massage career right out of massage school is understandably threatening and engenders hostility among those who prefer to believe this type of injury could never happen to them.
Some of the fear of admitting to injury comes from an understandable fear of losing work and income in a profession that is increasingly competitive and makes unrealistic demands on its therapists. This attitude was evident in one of my workshop participants who insisted she couldn’t stop doing a certain technique she found painful because “my clients come to me because I do that technique for them.” What a shame to so totally discount what you have to offer as a human being and reduce your value as a massage therapist to the sum of the techniques you do. Some of the apprehension comes from misplaced priorities. A massage school instructor recently told me she regularly encourages students to spread their clinic time out over several months, but many still cram it in right away to get finished faster so they can get licensed and begin making money.
One thing is certain: Massage therapists can be their own worst enemies. Although we’ve made great strides in the past 10 years, resistance to change of attitude, while very human, is one of the major factors holding us back from making further progress in preventing injury in our profession.
Prevention in the Next Decade
Even though we’ve seen positive changes regarding injury prevention, we still are left asking what the next 10 years might bring. Ideally, massage schools will train their instructors and administrators to recognize injury symptoms and institute systems to make sure students get proper treatment for those injuries, even if it means taking some time off from hands-on massage. They will teach injury physiology early in their programs, so students can understand that degenerative and irreversible changes in their tissues can occur if they continue “massaging through the pain.” They will teach a comprehensive curriculum that includes good body mechanics, but also the many other adaptations and adjustments needed to stay healthy throughout a long massage career.
I hope we’ll also see a return to holistic treatment, rather than the current emphasis on spot treatment. Such a change in attitude would be better for our bodies and for the client who needs to be educated that pressure doesn’t always equal relief or appropriate treatment.
Perhaps other members of the profession will come forward and recount their personal experiences with massage-related injury and how they overcame it. We’ve seen the influence that stars of sports (like Lance Armstrong) or film (like Michael J. Fox) can have in changing attitudes and creating awareness when they speak of their own struggles with illness. The more we can speak openly about this issue, the more we will combat the shame and denial that holds us back.
There are many questions yet to be answered about massage-related injury. We still do not have reliable statistics to indicate what percentage of practitioners become injured, what symptoms they most frequently encounter, etc. I hope to find some of the answers to these questions in a research study, I’m preparing on the prevalence of occupational musculoskeletal injury among massage therapy and bodywork students and professionals.
Associated Bodywork & Massage Professionals is my partner and sponsor for this study and you will find the results in a subsequent issue of Massage & Bodywork . Armed with these statistics, we’ll be able to more fully understand the scope of the problem and more effectively institute programs to combat it. I will continue to speak out about injury prevention, and I am working on the second edition of Save Your Hands!, which will contain more extensive documentation and updated information on the many aspects of repetitive stress injury among massage therapists, how to prevent it, and how to treat it when it happens. I look forward to continuing to develop constructive partnerships within the massage community in the next decade and beyond, to enable us to reach our common goal: reducing the risk of career-threatening injury among massage and bodywork professionals and students. This is the only way we can continue the advancement of the fascinating field of massage, which enriches our human experience.
Tips for Practitioners
Modifying your lifestyle and work habits is an essential factor in preventing injury. Once you are injured, the road to recovery can be long. These techniques can help you save your hands and your investment in your bodywork career:
- Get in shape. Plan on working out at least three times a week like any good athlete, including strengthening, stretching, and aerobics. Maintaining good circulation will help you heal any incipient injuries and keep them from developing into more serious ones.
- Avoid other hand-intensive activities. One body can only take so much hand-intensive work. Playing an instrument professionally or working as a typist, in addition to your massage work, will likely get you injured.
- Take care of your hands every day. They are the tools of your trade; treat them with care. Avoid opening stuck jars, lifting heavy objects, hammering nails — anything that can cause trauma or stress your hands.
- 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 while you work; keep your joints aligned in your hand and arm; use the larger muscles of the back and shoulder to create movement and your body weight (not your arm muscles) to create 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.
- Avoid massage techniques that cause you pain. There are thousands of techniques to choose from, so do only those that you can do comfortably.
- Monitor your work schedule. 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.
- Warm your hands before working. If your hands are cold, you do not have enough blood flow in your upper extremities to keep tissues pliable and remove waste products caused by micro-tearing. Warm up with stretching and light aerobic exercise before you start massaging.
- Get an electric table. They are standard for physical therapists; why should massage therapists use anything less? An electric table allows you to adjust the height of the table at any moment to enable you to remain upright and maintain good body mechanics.
- Take time between massages. If you don’t have enough time between massages to relax, stretch, breath, and change the sheets, you are putting yourself at risk for injury.
- Use other modalities in your massages. Hydrotherapy, aromatherapy, energy balancing, spa treatments, and more 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 toward your work. There are limits to what you can do for your clients. Respecting your own limits is healthy and will help you keep your upper extremities healthy.
- Treat injuries immediately and effectively. If you have pain or dysfunction intermittently or constantly for more than four days, see a physician. You are probably already injured, and letting it go will only allow the injury to worsen.
- Stay in touch with the signals your body is sending you. Don’t get so lost in treating your clients that you no longer can hear the signals of pain and discomfort that you need to heed in order to stay healthy.
- Lighten up. Don’t exhaust yourself with every client. Pace yourself throughout your day and your week so you don’t end up physically drained.
Lauriann Greene , L.M.P., is the author of Save Your Hands! Injury Prevention for Massage Therapists ( www.saveyourhands.com ). A graduate of Seattle Massage School, she has done extensive research, writing, and speaking on the subject of occupation-related injury among hands-on health practitioners.
1 Tappan, Frances M. Healing Massage Techniques (2nd Edition). Appleton and Lange; 1988.
2 Evans, Maja. The Ultimate Hand Book . San Francisco, CA: Laughing Duck Press; 1992.
3 Massage & Bodywork . Media kit 2004.
4 Holder, Nicole L., et al. Cause, prevalence, and response to occupational musculoskeletal injuries reported by physical therapists and physical therapy assistants. Physical Therapy Magazine 1999 July; 79(7).