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Ergonomics for MTs and Bodyworkers

By Rick Goggins

Originally published in Massage Bodywork magazine, February/March 2007. Copyright 2007. Associated Bodywork and Massage Professionals. All rights reserved.

Most massage therapists and bodyworkers are familiar with the term ergonomics. It's used to sell everything from toothbrushes to kitchen gadgets to cars. But ergonomics is more than a marketing term. It's a scientific discipline that can help massage and bodywork practitioners protect their own health and the health of their clients.

The term ergonomics comes from the Greek word ergon, meaning "work" and nomos, meaning "laws of." Ergonomics is literally the study of work, or more specifically, the interaction between people and tools, equipment, and environments at work.

One of the basic tenets of ergonomics is that people are fairly difficult to change. They have certain capabilities and limitations that can vary widely from person to person, but which are fairly well set within each individual. Ergonomists seek first to adapt the work to fit the worker, rather than expecting the worker to adapt to fit the work. When there is a good match between workers and their job, we find they are happier, more productive, and less likely to become injured.


Ergonomics and Injury Prevention
To understand ergonomics a bit further, think about sitting in a comfortable chair at home (hopefully you're in one now). Now, think about how it felt the last time you were in a seat on an airplane.

That's the difference between a job or workplace that fits and one that doesn't. And a poorly-fitting workplace can cause more than discomfort. When the physical demands of a job exceed the capabilities of the worker in it, or when a poorly-fitting workplace puts the worker in an awkward position for hours at a time, the end result can be a musculoskeletal disorder (MSD). For example, jobs that require workers to lift heavy loads while bending and twisting are known to have a high rate of low-back injury, and tasks that require working overhead for long periods of time, such as painting ceilings, tend to result in rotator cuff injuries.

Physical demands that are associated with MSDs, such as lifting, repetitive motions, or working in awkward postures, are known as risk factors. The term is used in ergonomics in much the same way that it is used in public health. You may have heard that smoking, obesity, and age are risk factors for heart disease. That doesn't mean that just because someone smokes, is overweight, and is older that they're going to have a heart attack. It just means that having those factors places them at an increased risk when compared to someone who doesn't. The same holds true for risk factors for MSDs.

For example, in a job that involves repetitive motions, forceful gripping, and bent wrists, such as scanning groceries at a supermarket checkout, you might see a small percentage of cashiers developing hand or wrist injuries, even though all of the cashiers are exposed to the same risk factors.

Everyone has a different susceptibility to MSDs, the same way people are at differing risk for heart disease due to their genetics, regardless of the other risk factors to which they are exposed.

Unlike smoking, a little exposure to risk factors for MSDs can actually be good for you. Too little activity can be just as harmful to us as too much activity, and a little bit of lifting, bending, and reaching--when done properly--actually helps us maintain strength and flexibility. The key to risk factors is to keep exposures down to a moderate level, and the exact amount that can be considered moderate is going to vary among individuals. See the table below for descriptions of some common risk factors for MSDs and the principles of ergonomics that can be used to reduce them to a moderate level.


Risk Factors for MSDs in Massage and Bodywork
You may have already recognized some of the risk factors for MSDs in the work you do. Many massage techniques involve repetitive motions combined with hand force, like deep effleurage or petrissage, while trigger point work typically involves sustained hand force. Long effleurage strokes from the end of the table may result in bending at the back and reaching. Positioning a client's limbs or head can involve lifting from an awkward position. Mobile practitioners may find themselves carrying heavy, bulky massage tables into clients' homes or offices.

The effects that the physical demands of massage work can have on a practitioner's body were investigated for a recent Massage Bodywork survey, which found that 77 percent of experienced practitioners had felt some form of pain or discomfort due to their work in the past two years. The survey also found that 64 percent of practitioners had symptoms serious enough to cause them to seek medical treatment, and 41 percent were diagnosed with a musculoskeletal disorder, such as low- back pain or tendonitis.

Understanding how massage and bodywork affects your body can help you find ways to protect yourself. The survey mentioned earlier found that the three most common sites of injury among practitioners are the thumbs, shoulders, and low back, so we can use these body parts as examples to further explain how injuries occur.
First, gently press the tip of your thumb into the palm of your opposite hand as if you were going to apply pressure to a trigger point there. For every one pound of force applied by the tip of your thumb, there will be ten to twelve pounds of force concentrated at your carpometacarpal (CMC) joint at the base of your thumb. Early on in a massage, the muscles around your thumb help to stabilize it and reduce the likelihood of damage to the joint. However, if you overuse your thumbs, muscle fatigue can set in and more of the forces at the CMC joint will be borne by the ligaments and cartilage. Repeated exposure can lead to micro-tears in tendons and ligaments, and damage to the cartilage, resulting in scar tissue, inflammation, joint instability, and possibly osteoarthritis.

Now imagine you're applying downward pressure with both hands to a client's low back while reaching out from the head of the table. You may work this way often, with your shoulders rotated inward and pulled forward, your elbows fully extended, your forearms are pronated, and your wrists may be bent back in extension. With just about all of your joints in a non-neutral position, the force has to come from smaller muscles and the potential for injury to the tendons and ligaments that help stabilize your shoulders is high. Non-neutral postures also tend to pull tendons across bursae or bony structures, impinge nerves, and reduce circulation, all of which can also lead to injury.

Lastly, consider what happens to your back as you lean forward over a massage table that is too low, too wide, or both. The muscles of your torso, hips, and legs need to contract to overcome the force of gravity pulling down on the mass of your upper body, which for women is approximately half their body weight and for men can be as much as 60 percent of their body weight. As you contract the muscles of your back to counteract gravity, the forces concentrate in the L5/S1 area of the spine. Now, add lifting a client's limb, such as a thirty-pound leg, to the equation. This movement can easily result in a ten-fold increase in compressive forces in the lumbar spine. In other words, lifting that thirty-pound leg can result in three hundred pounds of additional force at the L5/S1 vertebrae. Most low-back injuries that occur from this type of loading are minor sprains and strains of muscles and ligaments, but repeated exposures can cause cumulative damage to intervertebral discs, increasing the risk of disc bulge or herniation.

All of this discussion about compressive forces, micro-tears, and cumulative damage might have you worried about your career choice at this point. But before you put your massage table up for sale, consider that some level of stress and strain on the body can be good for you. The human body adapts to physical activity, and depending on the nature of the activity, that adaptation can either be positive or negative. A positive adaptation to the physical demands of providing massage includes stronger muscles, tendons, and bones, as well as increased endurance and improved movement patterns. Negative adaptations tend to result from repeated overloading or overuse of one or more body parts, poor body mechanics and movement patterns, and insufficient rest and recovery time, all of which can lead to injury.


Using Ergonomics for Yourself
You may have learned the importance of good body mechanics in massage school, through continuing education, or through experience. While good body mechanics is an important part of injury prevention, it's not ergonomics. Remember, ergonomics is about adapting the work to fit you, whereas body mechanics is about you adapting to fit the work. Experience has shown that learning good body mechanics alone is not sufficient to prevent injuries from occurring. You can still overuse your hands and wrists, even if you keep them in the best possible position as you work. And, there will always be situations where good body mechanics are not possible. For example, lifting and carrying a massage table will always be awkward, simply because of the size and shape of the table. Ergonomics goes beyond body mechanics to look for ways to reduce the physical demands on the practitioner through changes to tools, equipment, and the work environment, and for ways to provide adequate recovery time from physical demands through changes to massage techniques and scheduling.


Tools and equipment
The most obvious piece of equipment to consider in your ergonomic equation is the massage table. While you have your own considerations for features to look for in a table, such as price, color, and client comfort, the features that ergonomists would consider most important are weight, table dimensions (especially width), and adjustability.

Weight is an important consideration for students and mobile practitioners who may have to lift their tables several times a day, often out of awkward locations such as the back of a vehicle. Carrying tables is also an issue, due to their size and the fact that they need to be carried with one hand. In order to compensate for the increased load on one side of the body, the muscles of the low back on the opposite side must contract more. This leads to an asymmetrical loading around the lumbar vertebrae, which can result in disc damage.

A key ergonomics principle around lifting is to lighten the load, which would mean buying the lightest table you can find. It also means placing face cradles, bolsters, and other equipment in another bag that can be lifted and carried separately. Even with a light table, you should look into using a cart to transport it. Several manufacturers offer small carts specifically built for transporting massage tables. Look for larger diameter wheels that will roll more easily over obstacles and can make going up and down stairs easier. If you don't think a cart will work for you, at least use a carrying case with a shoulder strap long enough to cross over to the opposite shoulder. By slinging the case across your body this way, you can take some of the weight of the table on your shoulder and some on your hip. Alternate the shoulder that you carry the table on to avoid overusing one side of your body.


Table dimensions
The most important fixed table dimension to consider is width. With the American population getting larger all the time, it may be tempting to buy a thirty-one-inch wide table to provide more room for your clients. However, for most massage work, a wide table can lead to bending over, twisting, and reaching out, increasing stress on the shoulders and low back, especially for shorter practitioners.

A narrower table will be lighter and less bulky to lift, as well as providing better access to the mid-line of the client. Side extensions for larger clients are available for some narrow tables.
Along with width, the height of the massage table is very important to working posture. A general ergonomics guideline is that work requiring small, precise movements should be done at or a little above elbow height while seated in a neutral posture. Work involving larger movements and moderate amounts of force should be done at least a few inches below elbow height while standing, also in a neutral posture. As the force requirements of the work increase, the height of the work surface should drop so that body weight and larger muscle groups can be used to apply the force.


Working while seated
Translating these general recommendations into something specific to massage work, one recommendation would be to sit down while working on delicate areas of the body, such as the head and neck, with the table set at, or just below, seated elbow level. It may help to sit up a little higher than if you were sitting at the dinner table or at a computer. This will allow you to sit forward a little more and use your legs for stability. It can also help with leg room issues, since your legs will be a little straighter. Options for sitting higher include a high stool, a saddle chair, or an exercise ball. Stools or chairs should have wide bases for stability and wheels for mobility, although they should not roll too easily as this will make them unstable.


Working while standing
For relaxation massage of the torso and limbs, the practitioner should stand with the table set so that the client is a few inches below elbow level, so a "thicker" client or a client in side-lying position will require a lower table height. Deep-tissue work, passive stretching exercises, and other techniques requiring more force may require an even lower table setting.

Many therapists do a combination of techniques with each client, perhaps warming them up with relaxation techniques before initiating deep-tissue work. Therefore, they would benefit from a power adjustable table, although obviously this is not an option for a mobile practice. For practitioners who are happy with their current manually adjustable table and who aren't looking to invest in a powered table, retrofit kits are available that allows height adjustments for an existing table through a hand crank or power unit.


Hand tools
Another type of equipment you might consider adding to your practice is hand tools. There are several hand tools available for performing various modalities, especially for applying sustained pressure to trigger points. Many practitioners believe that all massage techniques should be done with the hands alone, in order to have a better feel for what is happening in their clients' bodies. It is true that the hands and fingertips are very sensitive. However, they are sensitive because the nerves run very close to the surface, and are therefore easily damaged. Sustained pressure with the fingertips, such as when applying pressure to trigger points, can result in localized compression of the nerves and the small blood vessels that nourish them. This can lead to inflammation, reduced circulation, and a loss of sensitivity or even complete numbness in the area, and it can take hours to resolve. Pressure applied with the fingertips has also been shown to increase pressure in the carpal tunnel, increasing the likelihood of damage to the median nerve, which supplies sensation to most of the fingers.

Rather than lose the ability to use one of your most important tools--your hands--consider using them only to locate trigger points, and then use a small hand tool to apply pressure. You can always rest a couple of fingers of your other hand on either side of the tool, so that you can regulate the pressure you are applying and feel for the release of the trigger point. When evaluating hand tools, look for ones that will allow you to keep your wrist straight as you apply pressure. Also, look for tools that you can grip comfortably using all of your fingers and your thumb, known as a power grip. Avoid smaller tools that you hold with the fingertips, since this somewhat defeats the purpose of using a tool. Also avoid any tools that place pressure at the base of the palm where the median nerve exits the carpal tunnel.

You should also take a look at the setup of your computer to make sure the chair, keyboard, and monitor are all at good heights that promote neutral posture. There is too much that goes into computer ergonomics to discuss in this article. However, there are some very good, free, self-help resources available online.


Scheduling and breaks
Adequate time to recover from the physical demands of massage and bodywork is critical to preventing injury. Recovery time reduces inflammation and replenishes energy and electrolyte stores. Recovery time also allows the body to repair micro-trauma and strengthen connective tissues exposed to strain. Not only is it important to limit the total number of massages you do in a week based on your body's capabilities, it is also important to look at the scheduling of appointments to make sure you don't overload yourself on any given day. Avoid scheduling clients that require deep work back to back, and if possible, avoid scheduling them in the same day, since it can take more than twenty-four hours for recovery.

The exact amount of time you should leave between clients is going to vary by the type of massage work you do and your own body's ability to recover. As a general guideline, if your muscles still feel noticeably fatigued, your hands are still hot and red, or your joints still ache, it's too soon to start another massage. You will experience some cumulative fatigue if you are doing several massages in one day, but you should definitely not be working to the point where your muscles are giving out, your hands are trembling, or you are feeling uncoordinated.

A good break should allow you enough time to go for a walk, perform a few stretching or relaxation exercises, drink some water, and mentally let go of the previous client and prepare yourself for the next. Charting your previous client and changing the table linens is not an adequate break. Surfing the Internet, playing computer games, or doing strength-building exercises are also not good break activities, since they involve repetitive motions.

In addition to breaks between massages, you should look for ways to provide your body some recovery time during massage sessions. In massage school, many of us were taught that in a good relaxation massage, your hands are always on the client, and there is an unbroken flow from one technique to another. Everything is done for the client, including lifting limbs and the head, while the client remains completely passive. In this type of massage, the only break for the practitioner comes when turning the client over. This type of massage can be very demanding, since it is an hour or more of unbroken activity with little opportunity for recovery. In the context of relaxation massage, it is possible to design a sequence that uses a variety of strokes applied with different motions and parts of the practitioner's body, which can provide for some recovery.

Don't think of giving yourself a break as being selfish in any way. The less fatigued you are, the better you'll be able to treat this client, and the other clients you'll see today and the rest of the week.


Planning for career longevity
In addition to thinking about your well-being while scheduling massage for the day or the week, you should also be thinking about how to stay healthy throughout your career. Even with the best ergonomics, body mechanics, and personal fitness, the physical demands of many massage and bodywork modalities can result in injury. Another reality is that we're all getting older. Age brings with it a gradual decline in strength and flexibility, and a slowing of the body's ability to recover from physical exertion. While you can hold onto much of your strength, flexibility, and endurance through regular exercise, some reduction in physical abilities is inevitable. As our physical capabilities decline, the likelihood that the demands of massage work will exceed them increases.

It is important to prepare yourself for these eventualities by making career choices while they are still options, rather than necessities. For example, you could use your continuing education as an opportunity to learn modalities that place less strain on the practitioner's body. Lymphatic drainage, craniosacral, Trager, positional release, and other modalities that do not require holding pressure or making forceful, repetitive motions can not only give your hands and arms a break, but also can add to the range of tools you have to treat clients whose conditions may not respond to traditional Swedish and deep-tissue techniques. One of the greater benefits of incorporating new modalities into your practice is learning the assessment techniques they use. A good client assessment will allow you to focus your treatments so that you can achieve the same or better results with less work.

Finally, you should consider expanding your career as a way of reducing your dependence on hands-on massage work for income. You could teach at a local massage school or community college, learn a modality well enough to teach it as continuing education, or work toward managing a group practice or spa. As an experienced practitioner, you have more to offer than just a pair of hands, and the sooner your career goals reflect that, the longer your career is bound to last.


Using Ergonomics for Your Clients
Most of your clients work, either at a formal job or around the house, and for most of them the better part of their waking hours is spent either getting ready to go to work, being at work, or commuting to and from work. It makes sense, then, to learn more about what your clients do on the job to help determine what may be causing some of their musculoskeletal issues you address in your sessions. You may already ask some questions on your intake forms about occupation and during interviews you probably get some details from your clients about specific work tasks that may have caused the soreness that initiated a visit to see you. You might consider taking this one step further and asking about their exposure to specific risk factors for MSDs in your intake forms. The risk factors in the table on page 64 are good general guidelines, but remember that a little exposure to risk factors is typically not harmful, so you might want to ask how often and for how long they are exposed before making any assumptions.

You might also ask your clients to describe or even demonstrate any tasks they do frequently at work, so you can get a sense of what muscles might be overused or overstretched during these motions. This can help you focus your treatments, and also help your client understand what repeated exposures might be resulting in chronic muscle soreness, weakness, or hypertonicity.

For example, people who work at computers have a sedentary job with prolonged seated work in a fixed posture, combined with highly repetitive hand and finger movements. The result is often reduced circulation and the formation of trigger points, especially in the neck and shoulders. Low-back soreness is also common among seated workers, since sitting often results in a loss of the inward, or lordotic curve in the lumbar area, which tends to strain the muscles and ligaments there. More serious injuries, such as tendonitis, can result in the shoulder, wrists, and hands from highly repetitive use of the keyboard and mouse. A good massage treatment for computer workers is to increase overall circulation, treat trigger points in the neck, shoulders, and low back, and reduce hypertonicity in the forearms in order to take pressure off the tendons in the hands and wrists.

You can also help your clients prevent discomfort through the use of ergonomics. While it takes years of education and experience to become a good ergonomist, massage and bodywork practitioners have enough background in anatomy and physiology to be able to explain how musculoskeletal disorders occur and discuss some possible solutions with their clients. Most people, given a little awareness of the issue and some education on the basic principles of ergonomics, are able to figure out solutions for themselves. One way you can help your clients is to point them toward some ergonomics resources, whether on the Web or through a local organization (see Resources, below).

You may be the first health-related professional workers come to when they begin experiencing symptoms, and you can play an important role in helping them recognize symptoms that require the help of a physician or specialist.

There is a whole field of medicine dedicated to treating occupational illnesses and injuries, which includes physicians, nurses, and therapists. By practicing occupational massage, you can join this group of professionals in helping to keep the workforce healthy and productive. By learning more about ergonomics, you can help both your clients and yourself prevent musculoskeletal disorders.

Rick Goggins is an ergonomist with the Washington State Department of Labor and Industries, and is a licensed massage practitioner. He has a bachelor's degree in biology from Columbia University, a master's degree in human factors from the University of Southern California, and is a graduate of the Alexandar School of Natural Therapeutics in Tacoma, Washington. He is working with Lauriann Greene on the second edition of Save Your Hands, a book on ergonomics and injury prevention for manual practitioners. Contact him at Ergonomics@LNI.wa.gov.




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