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| Self-Care For Therapists | |
| Written by Fiona Rattray, RMT | |
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Taking Care Of Number 1 As professionals, we may come to embody the conditions we studied in massage school. Postural dysfunctions, tendinitis, frozen shoulder, trigger points, hypermobility, carpal tunnel syndrome, sciatica and more may rise up to haunt us as a result of our work life. And, the longer one continues in a labour-intensive profession such as massage therapy, the odds increase for occupational injuries to occur. These injuries can result from overwork, poor posture, repetition, lack of stretching and exercise and aggravated pre-existing conditions. One recent magazine article on injury prevention stated that some massage schools teach proper “body mechanics” alone as the primary method of preventing occupational injury.1 Indeed, proper biomechanics are one part of the solution, but there is much more to well-being and injury prevention. Comparing Occupational Injuries To Other Health Care Professions While there is plenty of anecdotal evidence of massage therapists getting hurt at work, there’s not much research available in English on this subject. In fact, an internet search of the literature turned up one study in progress on massage therapists and occupational injuries at the Atlantic College of Therapeutic Massage: visit www.actmonline.com/intro.html to participate. Research shows that musculoskeletal injuries resulting from occupation are common among health care workers. I thought it might be useful to see what other health care professionals experience in terms of occupational injuries, especially those who use their hands and upper bodies frequently like we do. Physiotherapists
Looking After Your Body As therapists, it’s easier to dispense self-care information to clients than to follow this information ourselves. Something happened to me recently that served as a reminder of a simple principle. I’ve been in practice for 23 years, and regularly do preventive techniques for myself between clients. I felt I was in pretty good shape, no big complaints. So when a tornado touched down nearby in Fergus, Ontario, felling a number of trees on the property where I live, I decided to cut up the downed trees myself. Of course, I was wearing protective safety gear while using the chainsaw. I used as proper technique as possible to protect my back. The first tree converted into firewood pretty quickly. The next day I was at it again, and for two more days afterwards to finish the job. That’s when the combination of 10 pounds of chainsaw, prolonged vibration and 23 years of hand and arm use collided. It wasn’t that there was any specific pain, just a general achiness and lack of strength. A part of my brain got anxious about unpleasant future possibilities such as not being able to work. I redoubled my self-care plan, wondering just what was going on. Then it dawned on me that this was a prime example of overuse: not just at work, but also in my “recreational” time. I was not applying the principles I use in my workday to cutting up firewood: I’d taken no breaks, done little stretching and so on. After two weeks of massage treatments to my upper body, self care and avoidance of extra activities that stressed my hands and arms, things returned to normal. This experience also taught me more empathy for clients. General Self-care Tips You already know these general tips, so this is a reminder. At work:
Everywhere else:
Specific Self-care Tips Rotate through these self-care tips during the course of your work week. Some are appropriate for after each client, others for the end of the work day. Make yourself a handout of these tips and put it up at work and at home. Of course, if you use other self-care techniques, include them. Tip #1 What: Skin Rolling Where: Over the Forearm Extensors and Flexors Why: Reduce fascial restrictions How: Grasp the skin and subcutaneous tissue between your thumbtip and fingertips, raising these tissues into a little “roll” from the underlying fascia and muscle layers. You’ll feel your fascia being engaged. Slowly push your thumb along the skin, while at the same time your fingertips “walk” ahead over the skin, gathering it up and maintaining the raised roll of skin. The slower you go, the more you’ll feel any adhesions present and be able to treat them.
Tip #2 What: Fascial Spreading Where: Palmar Surface and Flexor Retinaculum Why: Reduce fascial restrictions How: Place one thumb onto the palmar surface of the other hand at the wrist and engage the palmar fascia, stroking towards the MCP joints. Start proximal to the pisiform and slowly stroke along the hypothenar eminence to the base of the little finger. The next stroke crosses the palmar surface and ends at the base of the fourth finger. The next stroke ends at the base of the third finger, and so on. The last stroke starts from the scaphoid and moves along the thenar eminence to end at the base of the thumb. *If your thumbs are hurting, use your olecranon or the proximal interphalangeal joints of the other hand instead. Tip #3 What: Fascial “Cutting” Technique Where: Cervical, pectoral, deltoid and sternal fascia Why: Reduce fascial restrictions, maintain range of motion How: Visualize the fascial planes over your neck, pectoral region and sternum. Place your fingertips on the area you want to treat, say the fascia over SCM and the scalenes. Keep your fingers together for support. Your terminal phalanges are slightly flexed. Engage the fascia by pulling with your fingertips. Start from the mastoid attachment of SCM along the posterior aspect of this muscle in a stroking or “cutting” action, all the way down to the clavicular attachment. Note any resistance in the fascia, and repeat the technique over these areas. Outline the fascia over the muscles as if you were working an anatomy colouring book. A surprising number of restrictions can be found in the fascia over anterior deltoid and the sternum. Tip #4 What: Muscle Stripping Where: Forearm Extensors and Flexors Why: Reduce trigger points, hypertonic muscles How: While you’re seated, place the arm you want to treat on the desktop in front of you, elbow flexed, palm down. Relax this arm. Using the ulnar surface of your other arm, start at the lateral epicondyle and slowly strip along the extensors towards your wrist and hand. Get as many aspects of the extensors as possible. Be sure to relax the hand of your treating arm, don’t clench your hand into a fist. Let your ulna do the work. You can use your olecaranon instead of your fingers to treat reachable trigger points. To reach the flexors, supinate the wrist you’re treating. Tip #5 What: Cross-Fibre Frictions Where: Hand and Arm Tendons/Tendon Sheaths Why: After you’ve performed an active resisted test on yourself and experienced tendon pain, leading you to suspect tendinitis How: You’ve noticed increasing pain along the tendon sheaths, for example of abductor pollicis longus and extensor pollicis brevis when you work. Could it be DeQuervain’s tenosynovitis? You perform Finkelstein’s test by making a fist, with your thumb in flexion inside your flexed fingers, then ulnarly deviate your wrist. Some discomfort with this test is normal, but a sharp pain along the tendons requires attention. Keep your hand in the Finkelstein’s test position. Gently palpate back and forth across both pollicis tendons with the fingertips of your other hand, looking for tender spots. Start at the proximal phalange of the thumb, and follow the tendons proximally over the metacarpal, even back into their muscle bellies and their attachments on the radius, interosseous membrane and ulna. Treat any tender spots or adhesions you find with cross-fibre frictions. Use a tolerable pressure that penetrates to the depth of the adhesion, and friction for short periods of time, say 45 seconds to a minute. Visualize that your fingertip is a pencil eraser and that you’re “rubbing out” the adhesion. Tenderness should decrease over this time. Move your pressure slightly along the tendon and repeat the process at the next tender spot. Don’t forget to stretch the muscles you treated and apply ice afterward. Tip #6 What: Stretches Where: Muscles that are short on you, for example iliopsoas, rectus femoris, pectoralis minor, scalenes, forearm flexors and extensors. Why: Lengthen tissue, prevent postural dysfunction, increase range of motion How: There are numerous stretching techniques ranging from slow, passive stretches to active inhibition techniques, where some combination of relaxation and contraction are used to lengthen tissue. You may need to use aids such as a door frame or strap to achieve the stretch – just like your clients need to do. The key is to do a stretch in a slow, gentle and sustained manner without causing pain. Hold a passive stretch for up to 30 seconds, and an active inhibition technique for up to 10 seconds. *Passive stretch for rectus femoris: Stand near a wall to support yourself. Keeping your hip in neutral position, flex your knee so that you can grab your foot and bring your heel toward your buttock. Keep your knees together, torso upright, stopping when you feel a stretch at the front of your thigh. Hold this stretch for 30 seconds. *Post-Isometric Relaxation (an active inhibition technique) for pectoralis major: Stand in a doorway with a hand on each door frame above shoulder height. Look straight ahead. Put one foot in front of the other and bend that knee slightly, leaning your trunk through the doorway until you feel the beginning of a stretch to your pectoralis major muscles. Now, with less than 10% of your strength, isometrically contract pectoralis major for a count of 10. Relax, exhale, and lean a bit farther into the doorway until you feel another stretch in the muscles. Repeat this cycle three times or more. Tip #7 What: Treat Trigger Points Where: Back muscles, posterior cervical muscles Why: Reduce referral symptoms, increase circulation How: Find a spot on a carpeted floor where you can lie down on your back. Pick an area – maybe rhomboids – that’s been exhibiting trigger point symptoms. Slide a tennis ball between you and the floor, and locate the ball at this tender area. Relax and allow the weight of your body to compress the muscle and its trigger point onto the tennis ball. Once the symptoms decrease, move the ball around to find any other trigger points and repeat the treatment. Finish with a stretch of the muscles you treated. Tip #8 What: Contrast arm rinse Where: Elbows, forearms, hands Why: Increase local circulation How: Every time you wash you hands and forearms at work, once you’ve finished soaping up, try this contrast rinse. First, use comfortably hot water to rinse over your elbows, forearms and hands for 60 seconds. Then, use comfortably cold water to rinse the same areas for 20 seconds. This ratio of 3:1, hot first then cold, allows for local vasodilation followed by vasoconstriction, preventing congestion in your hands. Tip #9 What: Ice massage Where: Inflamed tendons or muscles Why: Reduce local inflammation How: Take a paper cup, fill it with water and let it freeze overnight. At the end of a work day or after stretching, use ice massage to treat areas of inflammation. Tear back the paper to uncover the ice, and rub over the skin in circles for up to ten minutes. Don’t freeze your skin! Tip #10 What: Traction/Joint play Where: Carpals, metacarpals, phalanges of both hands Why: Mobilize hypomobile joints, reduce pain and spasm, increase nutrition to joint surfaces. Don’t use joint play on hypermobile joints. How:
What: Diaphragmatic breathing Where: Thorax Why: Decrease stress, increase relaxation How: First, assess your breathing patterns. Place your hands on your abdomen as you inhale normally, then exhale. How much movement is present? Next, place your hands on your lateral ribs as you inhale normally, then exhale, monitoring the available movement, (or lack of it). Then place your hands just below your clavicles as you inhale, again noticing the available movement. Your abdomen should expand first, then the lateral ribs and upper chest.
What About Self-Care For Your Mind And Spirit? Prolonged emotions, such as depression, fear and anger have a negative effect on the body, for example depressing the immune system response. As we know, western medicine has divorced the body from the mind and spirit. Other forms of medicine have a long tradition of just the opposite. Xiaolan Zhao, a physician originally trained in western medicine and then in Traditional Chinese Medicine puts it this way: “All aspects of an individual – physical, emotional, mental and spiritual – are interconnected and interdependent, and any one part cannot be understood except in relation to the whole.”1 Logically, then, self-care should include the whole therapist. So, how do you “do” self-care for your mind and spirit? Two tools are grounding and meditation. Years ago, massage schools in Canada used to teach concepts such as being grounded while working; this seems to have been dropped as curriculums focus on the western medical model. More recently, while supervising student clinics, I noticed clients coming in with headaches; by the time the treatment was over, the client emerged smiling and relaxed, but the (presumably) ungrounded student came out frowning, complaining of a newly acquired headache. Grounding Grounding is somewhat analogous to an athlete visualizing every detail of the perfect competition beforehand to achieve a personal best. When you work as a grounded therapist, your mind is clear and focused. You make decisions as you work. You’ll be “absorbed and attentive to what you’re doing even though you don’t deliberately contrive this. Your motions … are in a kind of harmony.2 There are many ways to ground yourself before a treatment. You could focus on your breathing, stilling your mind from all those chattering thoughts. As you wash your hands, focus on being tranquil, compassionate, non-judgemental; visualize negativity being washed down the drain. Stand quietly and feel your whole body, from your head right down to your feet; or imagine that your feet are growing roots right down into the earth. If you’re not a visual person, imagine stillness inside yourself. During a treatment, ground yourself by being focused on what you’re doing with this client in the present moment. The more you talk to the client, telling your own stories, the more your mind wanders. On the other hand, you may be mentally running through what should be on your grocery list, or silently reviewing what you did right or wrong with the previous client. Before you know it, you’ve detached from your palpation senses and your treatment is less effective. You may also realize after the treatment is over that you’ve been maintaining one position for too long and your muscles are tight. In another case, the client may be unburdening himself of some past or present experience that he needs to talk about that resonates with you, reminding you of your own experiences and “ungrounding” you. Instead of letting the information or image get stuck in your mind or body, imagine that you are like a screen door, letting everything pass through. If you visualized roots while initially grounding yourself, let the information be pulled down into the earth to be dispersed. Meditation Having a meditation practice is another self-care tool. Meditation can be a misunderstood concept in the west. It’s not just sitting in the lotus posture chanting Om. It’s a method of stilling the mind, achieving mental focus and physical relaxation. You get in touch with your spirit or your core being, whatever you consider that to be. You can meditate while you’re walking, sitting, standing or lying down. You can take workshops in traditional meditation techniques. Frequently, focus on the breath is used to bring you into the present moment. You could also be doing a kind of meditation when you’re watching a perfect sunset, listening to a child laugh, enjoying the flavours of a delicious meal, creating a piece of art, painting a wall, or shoveling the snow off a sidewalk. The key is being in the present moment. People who regularly meditate reduce their blood pressure and stress levels. When someone cuts them off in traffic, they’re less likely to fly off the handle. They tend to worry less about things they can’t control. They have gratitude for things like the air we breathe, the water in our bodies that sustains life. They have compassion for others. In Summary Combining physical self-care with emotional and spiritual self-care will give you a well-balanced foundation to keep yourself and your practice running for years. • Fiona Rattray, RMT, has been in practice since 1983. She is co-author of Clinical Massage Therapy and teaches workshops on self-care. You can reach her at www.clinicalmassagetherapy.com References:
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