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Self-Care For Therapists

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

• As recently as 2001, there was very little data on work-related injuries to physiotherapists. An Australian study defined work-related musculoskeletal injuries as pain lasting more than three days that physiotherapists felt was work-related. Job risk factors included manual techniques, sustained demanding postures, repetition and working injured. 56 per cent of the episodes of injury occurred in the first five years after graduation, with 40 per cent of respondents experiencing injury in the previous year to the study. Most injured physiotherapists continued to work, and modified their techniques.²
• 85 per cent of physiotherapists in Turkey experienced injuries once or more during their professional lives. Low backs, wrists, hands, shoulders and necks were involved. The specific injuries were tendinitis, vertebral disk problems, strains, sprains and joint degeneration. Like their Australian counterparts, the physiotherapists in the Turkish study kept working. They used occupational knowledge (27.5 per cent), rest (26.0 per cent), medication (25.6 per cent), exercise (19.7 per cent) and surgery (1.2 per cent) to do so.³

Dental Hygienists

• Dental hygienists in a Michigan study had a high rate of upper extremity tendinitis: shoulder (13 per cent of respondents), elbow (6 per cent) and hand/wrist (7 per cent).However, carpal tunnel syndrome (CTS), diagnosed using nerve conduction tests, showed up in only 3 per cent of respondents.  It’s interesting that CTS, often closely linked with occupations such as dental hygiene, was almost as prevalent in the general population.⁴
• A mail questionnaire sent to dental hygienists in Sweden found that competence at work, active leisure activities, management support and reduced work hours were predictors of good general health and well-being. However, more years in practice, a high work load, scaling of teeth, and family pressures increased the odds for musculoskeletal disorders to occur.⁵
• Dental hygienists are also warned about wrist anatomy and CTS. A square rather than rectangular wrist (seen in cross-section) may predispose an individual to CTS, as less space is available in the carpal tunnel. More women have this anatomic variation.⁶

Chiropractors

• A chiropractor described ligament laxity, cartilage degeneration and eventual osteoarthritis in the carpometacarpal joint of his thumb after 43 years of practice. The hands of another chiropractor “after years of adjusting … had shaped into an adjusting tool … the pisiform bone protruded.”  It was also noted that the thumb is not designed to be weight-bearing. Women may experience more thumb problems at  the carpometacarpal joint than men since the trapezium bone in women is shallower and the articular cartilage is thinner.⁷

Dentists

• One third of general practice dentists in one study experienced back problems related to their practice, while periodontists described neck and shoulder pain as primary problems. Dentists who exercised, worked shorter hours and improved their working ergonomics were less likely to injure themselves at work.⁸

References

1. Greene, Laurieanne. 2005. “Injury Prevention for Massage Therapists: 10 Year Retrospective.” Massage and Bodywork. February/March: 16-24.
2. West. J.D and D. Garderner. 2001. “Occupational injuries of physiotherapists in North and Central Queensland.” Australian Journal of Physiotherapy Vol 47(3):179-86.
3. Wermer, R.A., C. Hamann, A. Franzblau and P.A. Rogers. 2002. “Prevalence of carpal tunnel syndrome and upper extremity tendinitis among dental hygienists.” Journal of Dental Hygiene. Spring, 76(2):126-32.
4. Salik, Y, and A. Ozcan. 2004. “Work-Related musculoskeletal disorders: a survey of physical therapists in Izmir-Turkey.” BMC MusculoskeletalDisorders Aug 18;5:27 http://www.ncbi.nlm.nih.gov/entrez
5. Ylipaa, V., B.B. Arnetz, and H. Preber.  “Predictors of good general health, well-being, and musculoskeletal disorders in Swedish dental Hygienists.” 1999. Acta Odontologica Scandinavica 57(5):277-82. http://www.ncbi.nlm.nih.gov/entrez
6. Parker, E. “Preserve Your Arm and Hand Health” http://dimensions of dental hygiene.com/ddhright.asp?id=125
7. Hammer, Warren. 2003. “Joint Preservation is Necessary for Hands-On Practice.” Dynamic Chiropractic Vol 21, Issue 25.
8. Lalumandier, James A., Scott McPhee, Cathy B. Parrott, and Maureen Vendemia. 2001. “Musculoskeletal pain: Prevelance, prevention, and differences among dental office personnel.” General Dentistry  March-April pg. 160-66.

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:

• Use the proverbial “good biomechanics”.
• Don’t stay in one position for too long.
• When you’re recommending a self-care technique for a client, demonstrate the technique on yourself. While you’re showing the computer-using client skin rolling on your forearms, before watching him do the technique on himself correctly, you’ve just given yourself a little treatment. Hold that demonstration stretch for scalenes long enough for you to stretch your own muscles.
• After each client, stop and stretch a different body part. Stretch in a direction opposite to the posture you assumed while working.

Everywhere else:

• Observe yourself as if you were the client. What would you do to motivate this client to use all the wonderful self-care information you’ve just provided?
• Get regular massage therapy! And request that a reasonable portion of the treatment focus on your hands, arms, shoulders and neck as prevention. In my experience as a client, it seems that often, too much time is allocated to the back and not enough time to the hands and arms.
• Have a regular exercise program that includes stretching, strength training and cardiovascular exercise. Even a 30 minute walk three times a week is beneficial.
• Eat a balanced diet for your body type. Drink adequate amounts of water for your body type, don’t under- or over-hydrate. According to homeopathic advice, adequate hydration is achieved when you drink enough fluids to make your urine pale to colourless.
• Get adequate play and laughter. Exercise your mind with a hobby or activity.
• Get adequate sleep.

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.

• If your thumbs are hurting, drape a washcloth over the tissue you want to treat, using it to grip the skin below. Lift the skin and fascia using the cloth in a broad grip, and torque the tissue using short, dragging strokes.

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:

• Radiocarpal joint: Encircle the wrist of the hand you’re treating with the thumb, first and second fingers of the other hand. Your thumb is just distal to the radial styloid process, and your fingers are just distal to the ulnar styloid process. Gently squeeze your wrist, feeling the radiocarpal ligaments lengthening and the carpal bones moving slightly distal to the radius and ulna. Hold this traction. You can add small, painfree dorsal and volar glides of the carpals on the radius. Slowly release the traction.
• Carpometacarpal joints: Grasp the thumb metacarpal, and traction it distally from the trapezium. Hold, then slowly release. Now move to the index finger metacarpal and traction it distally from the trapezoid, holding then slowly releasing. Methodically work your way to each metacarpal in turn.
• Metacarpophalangeal and interphalangeal joints: Grasp the proximal phalange of the thumb, traction it distally from the metacarpal. Hold, then slowly release. Do the same thing for the distal thumb phalange. Again, work your way methodically through each finger in turn. Once you’re finished, compare how this hand feels to the hand that was doing the treatment. Better do the other hand too.

Tip #11
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.

• If you found that one of these areas was not moving, concentrate on breathing into the less mobile area. Place your hands there as you inhale. Focus on trying to move your hands out without forcing your breath.
• If you found that your upper chest was moving first, then your abdomen, or that your upper chest was moving much more than your abdomen (apical breathing), place your hands on your abdomen and focus your breath on moving your hands outward with inhalation.
• If all three areas are moving well, concentrate on breathing into your abdomen in a slow and relaxed manner. Feel your abdomen expand on inhalation as your diaphragm descends.
• Practice diaphragmatic breathing for 5 or 10 minutes at the start of your day, or before you sleep. It’s also useful in any stressful situation.
• A recent pilot study found that dysfunctional breathing patterns, especially apical breathing, were present in 85% of the study group who experienced chronic neck pain.*

* Perri, Maria A., D.C., and Elizabeth Halford, B.S., M.A. 2004. “Pain and faulty breathing: a pilot study.” Journal of Body Work and Movement Therapies. Vol. 8, No. 4, pp. 297-306.

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:

1. Xiaolan Zhao, CMD. 2006. Reflections of the Moon on Water. Random House Canada.
2. Pirsig, R. M. 1974. Zen and the Art of Motorcycle Maintenance. New York: William Morrow and Co.