Musculoskeletal Symptoms and Injuries Among Experienced Massage and Bodywork Professionals
Originally published in Massage Bodywork magazine, December/January 2006. Copyright 2006. Associated Bodywork and Massage Professionals. All rights reserved.
Many of us have heard stories of massage and bodywork practitioners who had to leave the profession because they were injured, burned out, or otherwise unable to continue meeting the physical demands of their work. Many of us may also have experienced symptoms such as pain, discomfort, and inflammation that might make us wonder if we, too, might have to consider a change.
Certainly, there is a tendency among healthcare providers to focus on the well-being of the client, sometimes to their own detriment. Other professions that involve direct caregiving, such as nurses and physical therapists, have surveyed their members and found high rates of injury, mostly musculoskeletal in nature. For example, one study found a prevalence of work-related musculoskeletal injury among physical therapists (PTs) and physical therapy assistants (PTAs) of 32 percent and 35 percent respectively. These results led the study authors to assert: "Although PTs and PTAs are recognized to be knowledgeable in prevention and treatment of musculoskeletal injuries, they are susceptible to sustaining occupational musculoskeletal injuries because of performing labor-intensive tasks."1
Among those labor-intensive tasks cited in the same study are "lifting, bending, twisting, reaching, performing manual therapy, and maintaining awkward positions for a prolonged period of time."2 Since many types of massage therapy and bodywork also involve these tasks, it is reasonable to suspect that massage therapists and bodyworkers would also be prone to work-related musculoskeletal injury.
Data suggest that these types of injuries exist in the massage profession. In Washington state, there are about 10,500 active licensed massage practitioners, of which approximately 150, or just over 1 percent, are employed by others and are therefore covered by the workers' compensation system. Out of this group of 150, only about 7 percent file claims for work-related injuries in any given year. Most of the injuries (about 55 percent) experienced by massage practitioners in the past five years were listed as overexertion from activities such as lifting equipment or clients and giving massages. These injuries occurred mostly in the lower and upper back, as well as to the upper extremities -- primarily shoulders, wrists, and fingers. The rest of the injuries reported were incidents such as slips and falls and skin reactions to products such as massage oils and creams. It is difficult to say if workers' compensation data are a good indication of the extent of the problem, however. We do know that work-related injuries tend to be significantly underreported, with workers choosing to treat their injuries through their health insurance or pay out-of-pocket rather than file a claim. Also, since most massage practitioners in the state are self-employed or work as contract employees, they are not covered by workers' compensation and do not show up in these statistics.
The incidence of occupation-related injury among massage therapists and bodyworkers has been reported in a number of books on massage and bodywork, and in the major massage industry magazines, including Massage Bodywork magazine. These publications have provided anecdotal and empirical evidence that occupation-related injuries affect a large number of massage and bodywork practitioners and can even occur during training at a massage school. The injuries most often discussed in these sources have been to the upper extremity. However, no statistical study has been published to date that evaluates the extent to which occupation-related musculoskeletal injury occurs within the massage and bodywork profession, nor suggests what steps should be taken to prevent such injuries from occurring. With so much available evidence suggesting that work-related injury might be an occupational hazard of massage and bodywork, there was clearly a need for a study to be undertaken on this subject.
The purpose of this study was to determine the incidence and prevalence of musculoskeletal occupation-related injury among massage therapists and bodyworkers by examining their self-reported symptoms and causes during the past two years. We also hoped to generate data that would allow us to gain a better understanding of the types of injuries this population encounters and to be able to correlate those injuries to the physical demands of the profession. Methodology
The survey contained 26 questions divided into sections on background and type of practice (e.g., years of experience, practice setting, primary modality), general health, injury prevention techniques used (exercise, stretching, receiving massage), symptoms of injury and specific injuries, and demographics (gender and age). Drafts of the survey were pilot-tested with active massage practitioners to make sure the questions were clear and easy to answer. Associated Bodywork Massage Professionals (ABMP) then created a web-based version of the survey and sent an e-mail to 1,000 of its members, selected at random from U.S. members living in all 50 states, inviting them to participate in the survey. Follow-up e-mails were sent to the same group to encourage participation for those who had not yet responded.
At the end of several weeks, 601 practitioners had responded to the survey, for a response rate of 60 percent. This response provided a large enough sample to allow us to assume that the results are representative of the overall massage and bodywork practitioner population in the United States, with a few exceptions due to survey limitations, which are discussed below. The raw data were sorted and analyzed using a database program. Incomplete surveys, where respondents had skipped one or more questions, were still included in the overall analysis. Since non-responses made up a very small percentage for all of the questions, it was felt that this would not change the outcome of the analysis.Demographics
The respondents were 78 percent female, while professional massage organizations, such as ABMP, report female membership in the 80 percent to 84 percent range, so the sample is fairly close to representing the gender ratio in the overall population of practitioners. However, there may have been a bias in the survey responses when it comes to age and years of practice, with older, more experienced practitioners being more likely to fill out the survey. In fact, 98 percent of the respondents have been practicing for more than five years. The average age of survey respondents is 50 years old, while the average age of Massage Bodywork readers is 42 years old. The average age of the workforce for the general population is around 45 years old. It is difficult to say why younger, less-experienced practitioners did not choose to take part in this survey. Perhaps they did not feel the survey was relevant to them, because they are new to the profession.Major Statistical Findings
From the responses to the survey, we were able to
generate several categories of health indicators. These included: reports of general health; symptoms of injury related to work; injury symptoms that lasted more than seven days; seeking treatment for symptoms; being diagnosed with an injury or condition; having to make changes to their practice due to symptoms (e.g., cut back on number of massages given, change techniques, etc.); and, considering leaving the profession due to symptoms or concern about being injured.
We also asked respondents about the eventual outcome of their symptoms, both the level and frequency at which they were now experiencing symptoms, as an indicator of chronic conditions.
We were then able to compare the relative health of groups of respondents based on how they answered other survey questions. We compared, for example, those who said they had received no injury prevention training with those who received training in massage school to see if this training or lack thereof made a difference in report of symptoms, injuries, diagnoses, and outcomes. The following are some of the findings of the survey, including a number of these comparisons.General health
On the whole, massage therapists and bodyworkers appear to be a healthy group. Among respondents, 89 percent rate their overall health as either "good" or "very good," 10 percent rate their health as "average," and only 1 percent rate their health as either "poor" or "very poor." Only about 8 percent of respondents reported that they smoked, while approximately 23 percent of the general U.S. population are smokers. Not surprisingly, survey respondents who smoke reported many more health problems across all health indicators than nonsmokers. Survey respondents reported diseases that can affect general health (like diabetes or heart disease) at or below the rates at which they occur in the general population. Health maintenance efforts
What do respondents do regularly to stay healthy and avoid musculoskeletal injury? Stretching, practicing proper body mechanics, and receiving massage were the most common responses (see Table 1, page 50). Almost two-thirds of respondents received massage at least once a month. It is interesting to note that less than half of the respondents incorporate strength-building and aerobic exercise into their health maintenance efforts, although both types of exercise can play a role in preventing musculoskeletal injury.Injury prevention training
Of the 601 survey respondents, 82 percent indicated they had received some type of work-related injury prevention training (see Table 2, page 50). To look at the effectiveness of currently available forms of injury prevention training, respondents who reported receiving this training in massage school were compared to those who reported having received no training at all. While both groups reported their overall health to be about the same, and both had about the same percentage reporting symptoms, the group that had no prevention training was more likely to have symptoms that lasted more than seven days and was more likely to have considered leaving the profession. Both groups were equivalent in the percentage that sought treatment for symptoms and received an injury diagnosis. However, respondents who had received injury prevention training were more likely to have a good outcome of their condition, with 72 percent reporting their symptoms completely resolved, or low level and infrequent, compared to 65 percent for the group that did not receive training.
To get an idea of what the injury prevention training might have covered, we compared the two groups on the types of activities they regularly practiced to prevent injury. The two groups were fairly equal in their use of stretching, strength training, aerobic exercise, self-massage, and receiving massage. However, a much larger percentage (74 percent) of the training group reported practicing proper body mechanics than the no training group (48 percent). Also, a smaller percentage of the training group reported leaving less than 15 minutes between massages and doing more than 30 hours per week of hands-on massage. It may be that, during their injury prevention training in massage school, this group learned the importance of using good body mechanics, taking breaks, and not overloading themselves by working too many hours.
To see if practicing proper body mechanics makes a difference in injury prevention, we compared those who reported regularly practicing good mechanics with those who did not (see Table 3, above right). It would appear that any advantage gained from body mechanics is slight at best. While those who practiced good mechanics reported a lower percentage of symptoms, as well as a lower percentage of symptoms that lasted more than seven days, they were just as likely to have sought treatment from a medical professional. The two groups were also very close in terms of percentage that had made changes to their practice or considered leaving the profession due to symptoms or injury. While good body mechanics is an important part of staying healthy as a bodyworker, by itself it may not be enough to prevent injury.Modality practiced
Survey responses seem to indicate that the primary modality practiced makes a difference in symptoms, injuries, and outcomes (see Table 4, page 51). We have combined respondents' reports of the type of massage they most commonly practice into categories, with modalities such as deep tissue, clinical, and pressure point work combined into a "heavy pressure'" group, and modalities such as reiki, movement therapy, and craniosacral combined into a "light pressure" group. Those who primarily practiced relaxation massage
were kept as a separate group for comparison purposes.
Practitioners of all modalities had a fairly high prevalence of symptoms, although there were some differences between modalities in terms of having longer durations of symptoms and seeking treatment
for symptoms. Practitioners in the "heavy pressure" group were more likely than practitioners in the other two categories to have symptoms that lasted more than seven days, more likely to seek treatment, and more likely to have been diagnosed with an injury when compared to practitioners who primarily offer relaxation massage. However, the "heavy pressure" practitioners were less likely to have considered leaving the massage profession. "Light pressure" practitioners, when compared with relaxation practitioners, were less likely to have symptoms, medical treatment, diagnosed injuries, or to have considered leaving the profession.
It's interesting to note that the "heavy pressure" practitioners were less likely to consider leaving the profession due to their symptoms or concerns about injury than relaxation practitioners, even though they seem to have more serious symptoms and diagnosed injuries. Hours of massage work
A variable of particular interest is the number of massage hours worked and its relation to symptoms and injuries (see Table 5, page 52). In many jobs involving repetitive motions and awkward postures, such as intensive computer work or electronics assembly, there is often a dose-response effect based on hours worked. As the number of hours per week of computer or assembly work increases, so does the percentage of workers who experience musculoskeletal symptoms and injuries.
Using the data from this survey we are unable to make a direct comparison between the number of hours worked and reports of symptoms and injuries, because we only asked about hours worked now, not during the period in which symptoms or injuries occurred (we could have asked for hours worked during that period, but we may not have gotten reliable answers if it was as much as two years ago). However, we did ask if symptomatic respondents changed the number of massages they give in response to their symptoms. So, if we look at only those respondents who did not report changing their hours, and assume that, on average, the hours they worked have remained fairly stable over the past two years, then we can compare symptoms and injuries across groups based on the hours they report.
Comparing the different ranges of hours worked, we found no clear dose-response effect. In fact, a number of the health indicators improved for respondents who reported giving more than 40 hours of massage per week when compared with those who worked between 21 to 30 hours per week. This does not necessarily mean that doing that much massage work makes you healthy; it may instead be that these respondents are able to do that much massage work because they are, in fact, in better health than the average person.
When looking into the effect of time left between massages, the same issues arise as when we looked at hours of massage per week. It is not possible to say for certain how much time respondents were leaving between massages at the time their symptoms occurred, although only three respondents specifically mentioned leaving more time between massages as a change to their practice in response to symptoms or injury (see Table 6, below). A comparison of the health indicators does not reveal any noticeable differences between the groups, except for those who leave 45 minutes or more between massages. In that group, a smaller percentage of respondents report having symptoms lasting more than seven days, seeking treatment, or being diagnosed with an injury. Work-related symptoms and injuries
It would appear that the majority of massage therapists and bodyworkers experience some type of musculoskeletal symptoms related to the work they do, with 65 percent reporting pain during or following massage work within the past two years. Adding in other symptoms, such as discomfort, soreness, numbness, and tingling, brings the overall percentage of practitioners reporting some type of musculoskeletal symptoms up to 77 percent, or 465 out of the 601 respondents. The most common locations for symptoms of pain were thumbs (30 percent of respondents), wrists (27 percent), shoulders (26 percent), and low back (25 percent). The most common location for symptoms of discomfort, soreness, etc., was the low back (25 percent), followed by the shoulders (24 percent), thumbs (23 percent), neck (21 percent), and hands (21 percent). Many respondents reported pain or discomfort in more than one part of the body in the past two years.
Most of the 465 respondents who reported symptoms said they lasted seven days or less (69 percent); however, 8 percent of respondents had chronic conditions with symptoms lasting more than six months. Among this symptomatic group of 465 respondents, 298 respondents (64 percent) sought medical treatment for their symptoms, with many respondents going to more than one type of healthcare provider. Not surprisingly, the type of medical practitioner therapists visited most often was another massage therapist (80 percent of those seeking treatment), followed by chiropractors (69 percent), and acupuncturists (30 percent). A preference for non-allopathic healthcare providers is further demonstrated by the fact that only 19 percent of this group sought treatment from a physician and just 14 percent visited a physical therapist.
Of the 298 who sought treatment, 247 (83 percent of those seeking treatment, 41 percent of all survey respondents) reported a diagnosis by a practitioner whose scope of practice includes diagnosis (i.e., chiropractor, physician, naturopath). A number of respondents who reported visiting only other massage therapists also reported diagnoses, and these were excluded from the analysis. A total of 129 respondents reported two diagnosed conditions in the past two years; an additional 35 reported three or more diagnosed conditions.
Overuse syndrome was the most common diagnosis, followed by tendinitis/tenosynovitis and low-back strain (see Table 7, below). The parts of the body most often associated with these injuries were the shoulders, thumbs, low back, neck, and wrists in that order. When looking at the locations of musculoskeletal disorders among the general working population, the most common parts of the body injured are low back, wrists, and shoulders. This difference would seem to indicate that there are unique exposures to work-related risk factors for injury inherent in massage work, and that specific training, work practices, and equipment may be required to help prevent injury.
Number of % of 247 % of all 601
Diagnosis respondents diagnosed respondents
syndrome 60 24% 10%
tenosynovitis 52 21% 9%
Low-Back Strain 46 19% 8%
back strain 45 18% 8%
Sciatica 23 9% 4%
Syndrome 22 9% 4%
Rotator cuff tear/
tendinitis 11 5% 2%
Syndrome 9 4% 2%
Epicondylitis 7 3% 1%
Bursitis -- shoulder 6 3% 1%
Other 33 13% 6%Activities that caused or aggravated symptoms
Most respondents identified applying pressure, giving massage, and standing for long periods of time as the primary contributors to their injury (see Table 8, below). A significant portion (21 percent) said that non-work-related activities were at least partially responsible for their symptoms.
Which of the following activities, if any, do you believe contributed to your injury?
Contributing Number of % of 465 with
activity respondents symptoms
Applying pressure 218 47%
Giving massage 176 38%
Standing for long periods
of time 96 21%
Other non-work related 96 21%
Positioning or holding client's
limbs or head 88 19%
A particular massage technique 65 14%
Working at the computer 58 13%
Lifting or carrying portable
massage table or other gear 50 11%
Other work related 32 7%
Sitting for long periods of time 10 2%
Applying pressure was again mentioned the most often as an activity that aggravated symptoms, with standing for long periods and giving massage switching order in the next two positions (see Table 9, below). Lifting or carrying massage tables or other equipment was more likely to have aggravated existing symptoms than to have caused them in the first place. This is especially true of those who reported symptoms in the low back, which can make lifting difficult.
Do any of the following activities in your practice make your symptoms worse?
Aggravating Number of % of 465 with
activity respondents symptoms
Applying pressure 153 33%
Standing for long periods
of time 90 19%
Giving massage 84 18%
Positioning or holding client's
limbs or head 69 15%
Lifting or carrying portable
massage table or other gear 62 13%
A particular massage technique 59 13%
Working at the computer 53 11%
Other 40 9%
Sitting for long periods of time 25 5%Effects from prior accidents
Out of the 601 respondents, 282 or 47 percent reported having had a major accident or injury to the upper or lower extremities, back, or neck (see Table 10, below). The most common body part injured in an accident was the neck, with 25 percent of all respondents reporting that location. The next most common injury locations were the low back (17 percent) and the shoulders (15 percent). Out of the 282 who reported a prior accident, only 53 reported no symptoms related to massage work, leaving 229 respondents (38 percent of all respondents) whose symptoms during massage work may have been in part due to an earlier accident or injury. The most common causes of injuries were automobile accidents, household accidents (e.g., falling from a ladder), and sports injuries. It may be that these prior injuries, if not fully healed, would have made this group more susceptible to work-related musculoskeletal symptoms. This increased susceptibility can be seen when comparing the percentage of those who reported both a prior injury and work-related symptoms (81 percent) with those who reported no prior injury but had work-related symptoms (74 percent).
Prior Accident Number of or just after
or Injury Respondents massage work
Yes 282 229
No 302 223
However, when looking more closely at the prior injury group, only 65 of them (11 percent of all respondents) listed non-work related injuries or activities as one of the causes of their symptoms during massage work, and only 21 (4 percent) listed non-work related injuries or activities as the only cause of their symptoms. Even though their prior injuries may have made them more likely to have work-related symptoms, the majority of respondents in this group attribute their symptoms to the demands of massage work.Changes to practice
When asked if their pain or symptoms had ever caused them to make changes to their practice, 260 responded "yes" (56 percent of those with symptoms, 43 percent of all survey respondents) (see Table 11, above right). Of this group, the most common change reported was to alter massage techniques. Almost half of this group reported doing fewer massages in response to their symptoms, and 21 percent actually stopped doing massage for a period of time. Of those who reported making other changes, common responses included changing body mechanics, increasing self-care, leaving more time between massages, no longer using a certain body part (e.g., thumbs, elbows) to apply pressure, changing the height of the table, or sitting more often during the massage. It is difficult to say which, if any, of these changes were effective in preventing further symptoms, since most of the respondents reported more than one type of change.
Surprisingly, 41 percent of those with symptoms chose not to change the way they practice massage in response to those symptoms, even though the majority of them believed it was massage-related activities (applying pressure, positioning a client) that caused or aggravated their symptoms.
Have you ever had pain or other symptoms that changed the way you practice massage work for any length of time?
Changed Number of % of 465 with % of all 601
practice? respondents symptoms respondents
No 192 41% 32%
Yes 260 56% 43%
No answer 13 3% 2%
If yes, which of the following did you change?
Changes Number of % of 260 who % of all 601
made respondents made changes respondents
techniques 181 70% 30%
massages 116 45% 19%
Stop for a period
of time 55 21% 9%
Change careers 6 2% 1%
Other 54 21% 9%Injury and symptom outcomes
Most symptomatic respondents had good outcomes for their symptoms, with 11 percent reporting their symptoms to be completely resolved and 58 percent still having infrequent symptoms at a low level (see Table 12, page 56). However, 21 percent reported low level, but frequent symptoms; 3 percent are still experiencing high level, but infrequent symptoms; and an unfortunate 4 percent reported symptoms that are both high level and frequent. Among those who reported initial symptoms, almost 9 out of every 10 have some type of on-going symptoms. In other words, among all survey respondents, about two-thirds of practitioners are experiencing recurring symptoms.
Frequency of symptoms appears to be more important than level of symptoms among the 105 respondents (23 percent of symptomatic and 18 percent of all survey respondents) who considered leaving the massage profession due to symptoms or fear of an injury. Half of those who reported their symptoms to be occurring frequently at a high level had considered giving up massage work as a result. Those who reported that their symptoms had completely resolved were least likely to consider leaving the profession.
Symptoms Number of Considered leaving
outcome respondents the profession
High level, frequent 18 9
Low level, frequent 99 40
High level, infrequent 13 2
Low level, infrequent 271 49
Completely resolved 52 4
(8%)Perspective on the Results
There appears to be a lack of coherence in the way massage and bodywork practitioners think about the physical demands of this type of work in relation to their health. Most therapists described their overall health as "good" or "very good," yet three-quarters of them report having experienced some level of musculoskeletal symptoms in the past two years. Around 80 percent of symptomatic respondents attribute their symptoms entirely to massage work-related activities, yet 41 percent of these respondents chose not to change the way they practice massage as a result.
Half of all respondents reported seeking treatment for their symptoms, and four out of 10 were diagnosed with a specific condition. Almost 90 percent of those who reported symptoms are still experiencing them to some degree, although for most, their symptoms seem to be at a level that allows them to continue in the profession. Still, almost one out of every five practitioners has considered giving up the profession due to symptoms or injuries.
These symptoms and injuries can have an economic impact on practitioners as well. Almost one out of five respondents reported having to reduce the number of massages they did in response to symptoms or injury. One out of every 10 respondents reported stopping completely for a period to recover. Only 1 percent of respondents reported changing careers as a result of their symptoms, but there may be many others who have also changed careers and, as a result, not maintained their ABMP membership and therefore did not have access to the survey.
It would appear from the survey responses that massage school is the most effective environment for injury prevention education. While some education is better than none, the large number of practitioners who are still experiencing symptoms and injuries even after receiving training seems to indicate that the training is inadequate.Limitations of the Survey
This was a cross-sectional survey; that is, it looked at only a short period of time across the study population, rather than tracking their activities and well-being over a long period of time. Therefore, it is not possible to draw definitive conclusions about cause and effect, since we do not know if one event preceded another. For example, we are unable to reliably compare the number of hours worked with symptoms and injuries, because we asked only about hours worked now, not during the period in which symptoms or injuries occurred. We could have asked for hours worked during that period, but we may not have received reliable answers if it was as much as two years ago. For similar reasons, it is difficult to draw conclusions about the effect of the length of time left between massages.
There are also several potential biases in the data. All surveys like this one depend on self-reporting of activities, health conditions, and symptoms, all of which can be a source of biased responses. For example, a number of respondents reported a diagnosed condition, but did not report seeing a healthcare practitioner whose scope of practice includes diagnosis and, therefore, could not be counted in the results for this parameter. Another limitation worth noting is that the survey respondents were both a little older and had a longer tenure in the profession than average. For this reason, it is not possible to draw conclusions about less-experienced practitioners due to the lack of response from that group.
There is an additional bias that could mean the
survey results understate the extent of the problem. Practitioners who are no longer active in the profession are probably less likely to still be members of ABMP, and were less likely to have taken this survey. There-fore, we may be seeing a "survivor effect" among those who responded to this survey. In other words, the respondents have found ways to continue working in the profession, despite the fact that the majority of them are experiencing some level of musculoskeletal symptoms due to work. If the level and frequency of symptoms that practitioners experience is one of the reasons they decide to leave the profession, then the problem may be even more widespread than this survey indicates, since those suffering the worst symptoms may have already left the profession. The anecdotal and empirical evidence cited at the beginning of this article would tend to support this assertion.
There were several other questions we were unable to answer due to limitations in the survey design and in the types of responses we received. We were unable to assess how early in a massage career symptoms and injuries might occur, since fewer than 2 percent of respondents had worked in the field for less than five years. We were also unable to compare self-employed practitioners with those who work for someone else to see if having more control over working conditions provides an advantage, since almost all respondents (98 percent) reported that at least part of their practice was self-employed.
Even with the limitations of this type of survey, the results obtained by this study clearly indicate the need for further research on work-related injury among massage and bodywork practitioners. A more complete, fully-funded research study is needed to establish the extent to which work-related injury is an occupational hazard of massage and bodywork and define the measures that should be taken to effectively prevent such injuries.Conclusions
We have always known that work-related injury in the massage and bodywork profession exists. This study strongly indicates that injury is a significant problem in this profession. Any profession that presents ongoing, significant risks to the health of those who work therein, and has a high attrition rate as a result, will have difficulty maintaining its integrity and thriving in the long-term. In a profession that, by its very nature, is meant to promote well-being and health, it seems unthinkable not to take dramatic steps to make sure this issue receives the attention, education, and funding necessary to give every massage therapist and bodyworker the possibility of having a long and healthy career as a professional practitioner. 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.Rick Goggins, C.P.E., L.M.P., is a senior ergonomist with the Washington State Department of Labor and Industries and a licensed massage practitioner. Contact him at firstname.lastname@example.org.
References1 Holder, Nicole L. et al. Cause, Prevalence and Response to Occupational Musculoskeletal Injuries Reported by Physical Therapists and Physical Therapy Assistants. Physical Therapy. Vol. 79, Number 7, July 1999; 642-652.