Positive Health Online

Over 5.4 million working days were lost last year to work-related conditions affecting almost half a million people. It is estimated that 1.2 million workers suffer musculoskeletal disorders caused by their work, resulting in the loss of ten million working days per year. The self-reported absence rate due to sickness or injury in the health sector is 5.2% – the highest among industries, based on the percentage of employees absent for at least a day in a previous week.[1] Every day at least six workers leave jobs forever because of RSI (Repetitive Strain Injury). With longer time off work, the chances of ever getting back to work decrease rapidly. Only 25% of those off work for a year and 10% of those off work for two years will return to productive employment.[2]

Who are These Statistics?

Angela, a single woman in her 30s, is a therapist from the North. She works full-time on a self-employed basis. Several months ago, she started to suffer pains in her hands due to massage. Like most, her symptoms were more in one hand than the other. She naturally put more of her work through her less-painful hand, only to find her level of pain rose to equal in both hands. Being self-employed and having no other source of income, Angela continued to work through the pain in order to make ends meet. Unfortunately, although the clients kept coming, as did the overheads and expenses of her business, Angela's ability to cope didn't. Already injured, and without the opportunity to rest, Angela soon found herself unable to use her upper limbs on the whole due to compounded repetitive injury. This made not only her practice impossible, but also most other simple everyday tasks we take for granted.

Jill, a married woman in her early 40s, is a therapist from Yorkshire. While a very keen therapist who once had a full-time practice, Jill has recently had to switch to part-time practice due to injury. She now has to schedule her days to compensate for her injuries, knowing that she can only do a certain number of treatments before she is in too much pain to continue. This has had a significant effect on her income and she is thankful that she has an additional source of income to help keep her afloat. However, no amount of money is helping to satisfy Jill's desire to practise or ease her disappointment in having to cut down her client load.

Liz, a married woman in her 50s, is a therapist employed by a salon chain. She came into therapy as a second career and really enjoys the variation of working in a salon environment. Unfortunately, Liz is finding the intensive schedule very physically demanding and struggles to deliver a quality massage toward the end of her working day – which is usually 12 hours long. While Liz is concerned about the physical aches and pains she suffers in her hands, arms, and back, she is also concerned about her position within the salon, as her employer is starting to notice the empty evening slots in the appointment diary.

Sarah, a single woman of 19 years, is a therapist just starting out as an employee in a trendy rural salon. She only recently finished all of her training, quite excited about the prospects ahead of her. Her case, however, is quite different from that of Angela, Jill and Liz, because her injuries have not resulted from her massage schedule. Sarah has suffered a traumatic injury that has resulted in extreme permanent damage to her hand, leaving her in no doubt that her budding career as a therapist has ended before it's begun. While the nature of her injury is different, like all the others, she is left frustrated and severely disappointed that she cannot pursue the career she invested so much time in learning. Determined not to give up, Sarah has tried massaging with one hand only, but tires quickly and is not confident in treating paying clients.

What is happening in these cases?

RSI, Cumulative Trauma Disorders, Occupational Overuse Injuries, Work Related Upper Limb Disorders, back pain, neck pain, etc. These are common conditions that encompass many different injuries. These conditions arise for many reasons: as a massage therapist you are either at risk or already suffering because of the demands you place on your body during every treatment. And it isn't all musculoskeletally related. Demands placed on the upper limb and trunk in bodywork are analogous to those imposed on the lower limb during many sports and athletic pursuits. These 'industrial athletes' are susceptible to the same neuromuscular disorders as their 'athletic' counterparts. Unfortunately, industrial athletes do not always have the benefit of adequate training, conditioning, monitoring, and immediate post-injury care.[3]

The risks stem from issues as simple as posture, rest, and exercise. Poor posture throws off the body's balance and makes the wrong muscle groups work in the wrong ways for the wrong reasons. This leads to the obvious back and neck pain. However, poor posture hinders breathing and the nerves and blood vessels running into the arms, making the arms susceptible to the various conditions named above. The lack of rest from a demanding schedule or client load, especially working with poor posture, as well as use of excessive force to appease the pressure-loving client almost guarantees trouble. Even the stress of a large workload, especially if you are not the one in control of your schedule, contributes to these disorders. Simply performing over two hours of repetitive hand movement per day is enough to put a therapist into the risk category, but what therapist does not identify with at least half of the other risk factors mentioned here?

Tightness, discomfort, stiffness, soreness, or burning in hands, wrists, fingers, neck, or back; tingling, coldness, or numbness, or a feeling of heaviness in the limbs or head; clumsiness or lack of coordination or control; pain that wakes you up at night – especially in the early morning hours; frequent need to self-massage; pain; these are all symptoms of a larger, more serious problem. Of course, these conditions aren't always painful. Those famous therapist 'clicky wrists' are a sign of trouble.

The Whys and Hows of Hand and Arm Pain

Repetitive movements that disturb the delicate balance of muscles, tendons and ligaments in the hands cause disorders as previously mentioned. Delayed-onset muscle soreness is most likely caused by structural damage in skeletal muscle after excessive use and may take as long as 12 weeks to repair[4] – therapists don't have this option.

The nerves that supply the muscles and skin – refer back to your A&P (Anatomy and Physiology) – can be compressed or 'trapped'; this can be caused by tight muscles, inflammation of tissues, or misalignment of nerves resulting from repeated motions.

This compression is felt somewhere between the point of compression and the fingertips. Ulnar, radial, or median nerve compression can occur anywhere along the path they travel through, from the neck to the hand. Shoulder pain can be referred from a pinched nerve in the neck. Pain in the forearm, wrist, or fingers can come from a compression at the neck, elbow, or wrist level. Not uncommon in therapists is a 'double crush' injury where nerves become compressed in more than one place as a result of muscle tightness or tension in several places.[5]

Whys and Hows of Back Pain

Most people think back pain results from injuries through lifting heavy or awkward objects. Many back injuries, however, come from relatively minor strains that occur repeatedly over time. As you repeat irritating movements, minor injuries begin to accumulate and weaken affected muscles or ligaments. Eventually, the small injuries add up and a more serious injury can result – just like RSI in the hands and wrists.

A variety of factors contribute to these minor strains. Awkward postures increase strain on back muscles and can bend the spine into positions that can put pressure on discs and cause trouble. In the case of massage, when awkward postures are prolonged or repetitive, the risk of injury is greater.[6]

If you are out of shape, the chances for back pain are greater. Infrequent exercise can lead to trouble as well. Proper diet and gradual, regular exercise and stretching can all help to avoid back problems.

Finally, stress can lead to back pain. Stress at work or home can cause tension in muscles leading to tightness and muscle spasms. Although stress is part of everyone's life, excessive stress may cause backache.

The solution is to reach a balance in the body, in life, and in work with time to relax.[7]

Understanding How the Spine Works

Understanding how your spine works may help you correct and enhance your working posture.

Your discs are gel-like cushions that are vital to back health and efficient function. One of their primary roles is to act like shock absorbers and insulators between vertebrae. Not only do they have to cope with constant pressure, they have to absorb sudden shocks, compression, and twisting stresses, and allow limited movement of the spine.

Made up of semi-elastic rings of cartilage surrounding semi-fluid centres, disc composition allows for any compressive forces on the spine to be evenly distributed in all directions, spreading the load. The discs also allow rocking movement when the spine is bent – each rolling over its nucleus like a plank over a barrel. When the spine is bent forward, the nucleus is squeezed backward; when bent backward, the nucleus is squeezed forward. Hence, leaning forward by bending the spine causes more stress and pressure than maintaining a neutral spine or standing upright.

However, standing still in a fixed posture is not the answer to maintaining a healthy spine.

The fluid nature of intervertebral discs means that in order for the vertebrae to be stabilized while stacked on the discs, they have to be joined to each other by strong ligaments under constant tension. This tension puts a compression force on the discs in turn. In order to balance this force, there has to be a way of maintaining pressure inside the disc as well as outside, or it would collapse. Within the fluid that makes up the discs there are cells that require nourishment and a means of removing waste products, but these cells have no means of receiving nourishment from the blood due to the extreme pressure the discs are under. Instead, they rely on diffusion to maintain the required internal pressure while receiving nutriment and removing waste. Movement is the most effective aid to this diffusion.[8]

The Cycles of Pain and Movement

First there is pain, then the body adapts, beginning the Cycle of Pain.

Changes in posture and patterns of movement are like folds in a piece of paper. Paper folded along a line will bend along the same fold when stressed. The body is no different. Once a body makes a change in movement pattern to compensate for pain, the body adopts that poor pattern as the norm, resulting in unbalanced movement and joint stress that lead to a host of problems.

The Cycle of Pain is the result of moving in ways to avoid pain. The solution to the Cycle of Pain is motion.9 Mobilization, muscle stretch, and retraining posture and movement patterns restore normal function and improve integration to maintain status and minimize recurrences.[10] Restore movement and you can re-balance posture to move naturally, feel good, and be well.

Only when joints move freely through a range of motion can weak muscles gain strength, tight muscles stretch and short ligaments lengthen and adapt to balanced posture. This balanced posture leads to balanced movement that creates and maintains flexibility, stability and well-being.

The Cycle of Movement is the result of addressing ways to re-balance and strengthen the body, breaking the Cycle of Pain.

IPM's Role in Improved Posture, Back Health, Motor Skills, and Alertness

Traditional massage techniques are based on rigid ideas and positionings in relation to the massage couch. There should never be any extra contact with the couch or the client. The awareness of the practitioner is very much centred in the upper body – strokes delivered from the arms, with the weight of the arms and force for the strokes being borne by the shoulder girdle and the upper spine.

Injury Prevention Massage (IPM) techniques attempt to shift awareness and balance from the upper spine to the lower back and into the thighs and lower legs, easing the strain on muscles, joints and tendons of the upper body, as well as intervertebral discs and nerve endings which work in concert to hold the back upright. This allows the discs to function more effectively in their role as 'shock absorbers' to the vertebrae of the spine, and also brings about significant improvement in posture. IPM also stresses the importance of movement as the solution to rigid and damaging postures, ensuring the diffusion necessary to maintain happy, healthy discs. IPM also addresses the importance of continued movement after injury, as exercise promotes recovery and rest is only prescribed if essential.[11]

Injury Prevention Massage is about much more than merely administering massage without the use of your hands. It is an advanced massage approach that encompasses the best and most important aspects of several massage disciplines as well as essential elements of body health, balance, and awareness, offering priceless information on how your body should work, figuring out how your body currently works, and protecting yourself against injury – hands, wrists, shoulders, neck and back. The shifted awareness and improved balance and postural positioning all work together to more evenly distribute the workload to a greater area of the musculoskeletal system as opposed to making the structures of the back – muscles, discs, tendons, etc., bear the strain of constant flexation.

Not only does the focus on movement effectively address posture and back health, but plays a large role in stimulation of vestibular apparatus (proprioception) that increases balance and motor skills as well as alertness. The body usage inherent in IPM techniques lends itself to a sort of rocking motion which increases cardiac output, promotes respiration and stimulates muscle tone. The techniques develop the sense of proprioception, bringing about a conscious appreciation of the working of the body's neuroreceptors, especially those concerned with postural awareness.[12]

The ideas put forth in IPM philosophies combine to induce balanced movement, enhance posture, reduce pressure on spinal vertebrae and diaphragm, relieve tension and improve breathing capacity and alertness, producing a genuine sense of poise and equilibrium.

The Anatomy of IPM

Having addressed the postural implications of Repetitive Strain Injury, the most obvious question is how to take the hands out of the massage equation. Many therapists have experimented with applying strokes with different parts of the body. The one that makes the most sense is the arm. Through clinical experimentation, therapists have found several surfaces of the arm that make it a versatile tool.

The pronator teres and brachio-radialis, together with the deep and superficial flexors on the anterior surface of the forearm form a fleshy pad, the firmness of which can be varied according to the flexion of the wrist. This pad is perfect for performing effleurage strokes, as well as moulding around and into the joints and curves of the body to assist in muscular stretch. The deep and superficial extensor groups, along with the flexor digitorum profundus and flexor carpi ulnaris and abductor pollicis longus on the posterior surface of the forearm provide a soft but firm surface when using the anterior surface is not practical. Not forgetting the upper arm, the biceps brachii and brachio-radialis (again) work well with the lower fleshy pad to create a gripping mechanism for powerful tractions. Moving beyond the musculature, the skeletal points of the olecranon (humerus), styloid processes (radius and ulna), medial and lateral epicondyles (humerus), and indeed the ulna itself, are safe and effective replacements for thumbs and wrists for harmful traditional petrissage and deep strokes.

What to do?

If you are injured, take steps to correct the situation and maintain your demanding work by adapting your technique. If you are not suffering any symptoms, have the foresight to protect the most valuable tool of your work – your body. It is far easier to prevent these disorders than cure them once contracted. However, if you have the symptoms listed regularly when working, or as a result of your work, RUN, DO NOT WALK, to a health care provider right away. Early treatment is critical to limiting damage, trouble and frustration.

THIS IS NOT EXAGGERATION; by the time you have symptoms there has already been damage done. Ignoring pain once it arrives may result in serious injury. But all is not lost. Although there are no quick fixes, changes in techniques and work habits can allow healing to happen. Increased awareness of your posture and work habits is necessary to enable you to work safely and avoid further problems. That's where IPM came in for Angela, Jill, Liz and Sarah.

Angela started slowly and worked only within her range of ability, but the passive exercise for her damaged limbs offered by IPM techniques encouraged healing. Soon she was able to resume normal daily activities and after patience and persistence, Angela re-started her practice.

Jill is using techniques that have helped address both her overuse and posture issues and, as a result of the increased movement and stretch incorporated in these techniques, is more physically fit and active. All of these changes have given Jill the ability to see as many clients as she wishes in a day, pain free.

Liz is much happier in her work now, as her massage has improved considerably and her clients and employer have noticed the change. She is no longer suffering from the physical demands of her job, nor from the additional stress of underperformance, which was putting her employment in jeopardy.

Sarah continues to work in the salon and has a full massage schedule. Her confidence has increased and her ability and muscle tone is significantly improved. Her trauma has not left her without a career as she had feared – she has moved far beyond her own expectations and is a top earner in the salon, using techniques that provide effective massage without the use of the hands, while addressing the postural implications that accompany such a shift in working style.

References

1. Office for National Statistics. Labour Force Survey. HMSO. London. Summer 1994, Autumn 1994, Spring 1995.
2. Clinical Standards Advisory Group. Back Pain. HMSO. London. 1994.
3. Lucas A. Assessment & Treatment of Industrial Overuse Syndrome (Upper Limb), A Clinical Manual for Physiotherapists. 2nd Edition. Out of print.
4. Evans W. Exercise-induced Skeletal Muscle Damage. Phys. Sports Med. 15(1). 1987.
5. Montgomery K. Carpal Tunnel Syndrome: Prevention & Treatment: The Repetitive Strain Injury of the Wrist & Hand. Sports Touch. USA. ISBN 1878069357. 1995.
6. Deyo R. Occupational Back Pain. Hanley & Belfus. USA. ISBN 0932883494. 1988.
7. Campbell A. Beating Back Pain Through Conventional & Complementary Methods. Mitchell Beazley. London. ISBN 1840007451. 2004.
8. Oliver J and Middleditch A. Functional Anatomy of the Spine. Butterworth Heinemann. London. ISBN 0750600527. 1991.
9. Weiniger S. Postural Rehabilitation & Biomechanics. Seminar. Arizona, USA. 2003.
10. Prosser R et al. Rehabilitation of the Hand & Upper Limb. Butterworth Heinemann. London. ISBN 0750622636. 2003.
11. Snashall D. ABC of Work Related Disorders. BMJ Publishing Group. London. 1997.
12. Blair SN et al. Reliability of Long Term Recall of Participation in Physical Activity by Middle-Aged Men & Women. American Journal of Epidemiology. 1;133(3): 266-75. Feb 1991.