Editor's note: Sandy Fritz, a practicing massage therapist for over 20 years, is the author of Mosby's Fundamentals of Therapeutic Massage and co-author of Mosby's Basic Science for Soft Tissue and Movement Therapies and other massage textbooks such as Mosby's Massage Therapy Review. She is the owner and director of the Health Enrichment Center, Inc., School of Therapeutic Massage in Michigan, and maintains a private practice for professional football players. Sandy also provides consultation to many massage schools in development. I've spent many hours pondering how I could encourage practicing massage therapists to improve their body mechanics. Because proper use of body mechanics can enhance the longevity and success of your career, continuing education regarding body mechanics should be stressed to all massage therapists.

Most research in ergonomics had focused on elements of lifting and motion. Massage application is more about the application of compressive force. Adaptation of biomechanics for those who lift and move is counterproductive for massage application. Over and over, I hear clients ask for more pressure without being poked and jabbed. The major goal for massage is to apply an appropriate broad-based compressive force to soft tissue, using the least amount of physical effort.

Massage has become a system unto itself. The historical basis for massage was as more of an integrated system utilizing movement, exercise and massage. Seldom was massage applied for a full hour. Now the one-hour massage is the expected standard for massage professionals. Five massage sessions per day is necessary for most to achieve financial stability in a typical workweek. No wonder that a recent study by Watson (reported by Gerry Pyves in the Journal of Bodywork and Movement Therapies, vol. 5, no. 3, July 2001) showed that 78% of massage professionals have experienced a work-related injury. Something must be done to help our profession. A change in paradigm about how massage is delivered is necessary. The idea that the hand is the primary delivery tool is outdated. The forearm, the flat space below the knee and the foot are better suited for sustaining the abnormal loading of the joints and repetitive movement strain on the joints and soft tissue required when giving massage.

Compressive force is applied 90 degrees in relationship to the body contact. This means that the client needs to be positioned so that you can lean against an upward slope on the body and maintain about a 45-degree angle at the shoulder. When the knee and foot are used, a 90-degree angle against the tissue can be achieved easily.

The joints need to be stacked and stable; the gliding motion should be provided by moving the feet in a forward position, instead of leaning at the waist and reaching forward. Avoid petrissage or kneading movements. The same effect can be achieved by applying compression to the tissues, then moving the adjacent joint actively or passively.

Are you asking yourself, "What can I do to improve my body mechanics?" First, be aware that there could be a problem, and the problem may not be apparent to you. Just because you have your education under your belt and practice massage does not mean you are using your body in the most efficient way.

There are many objects to consider when discussing body mechanics, including the massage table, floor mats, stools and chairs.

Is your table the proper height? As a general rule, your fingertips or first knuckle should reach the top of the table when your arms are hanging at your sides. This varies depending on if you have a long or short torso, legs or arms. If your table is a little short, you will be able to accommodate by widening your stance, but will often end up bending at the waist and developing low back fatigue. A table that is too tall will cause you to use upper muscle strength instead of leaning and using leverage to apply the compressive forces. Test your table. Are you thinking it's too tall or too short? If so, experiment to see if it feels more comfortable set at the suggested height. If it was too tall and you adjusted it, at the end of a day of practice you may feel less lethargic because you used less upper body strength. If it was too short, your back will ache. More often than not, raising the table a bit helps.

One way to notice incorrect body mechanics (besides the pain you may be feeling by the middle or end of your day) is by using a mirror to check yourself frequently in different positions:

• Are you monitoring the position of your feet?
• Are your feet following the same direction of force as being applied to the body? If the foot is externally rotated enough so that the pelvis rotates, low back pain will result. (Often therapists are taught to assume a stance where the weightbearing foot is at a right angle to the direction of force being applied. Over time, this stance will strain the knee and low back.)
• Is your weight on the correct foot? To lean such that pressure is delivered from the body weight and not muscle force, the weight bearing foot needs to be opposite the weight-bearing arm.
• Are you utilizing your weight for compressive force leverage, or are you using muscle force?
• Are you using good posture, balance, and are you using the strongest and largest muscles to perform your work?" If not, you will experience muscle aching.
• Do you avoid the use of your hands (especially the thumbs) to provide massage?
• Are your elbows bent? If you use your hand, repetitive strain injury will result. If you bend your elbows, your shoulder and wrist will ache. Learn to use your forearm, knees and feet to achieve the same results. This will require learning to work on a mat on the floor, or climbing on the table to apply the methods.
• Are you moving up and down the body by changing foot position, or are you reaching for strokes? If you do not move your feet, your shoulder will be forced to move back in forth in the socket, creating a tendency for bursitis and muscle aching.
• Are your knees bent more that 15 degrees? If so the compressive force in the knee capsule has increased and the muscles have to provide stability. Lock the back weight bearing leg into normal extension.
• Are you maintaining a five-point stabilized posture for the torso by having the shoulder girdle, pelvic girder and head on the same plane, or are your shoulders twisted in a direction different than the hip? Is you head up, or are you looking down at your work? If your torso is twisted, you will feel muscle aching and fatigue, perhaps combined with shoulder and low pack pain. If your head is dropped, you will experience neck, shoulder and low back tension.

If you were unable to notice incorrect uses of your body mechanics and think you are doing just fine, wouldn't you rather be safe than sorry? Ask a few other massage therapists to get together so you can evaluate each other. Watching each other will provide more objective feedback. If you are only doing two or three massage sessions per week, you may be able to get by with bad body mechanic habits, but if your are doing two or more massage sessions per day to total 10 massage sessions or more per week, injury will likely result.

Here are some ways to do a self-test:

1. Are you using leverage and using your body weight to provide pressure?
2. Are you using your forearm to apply most of the strokes?
3. Can you use your knees and feet to apply massage methods?
4. Are your arms and hands relaxed while giving a massage?
5. Are you using a proper wrist angle and staying behind the massage stroke to protect the wrist? Are you keeping your elbow straight?
6. Are you maintaining a relaxed hand and wrist while giving a massage?
7. Are you keeping the lower back straight and avoiding bending, twisting or curling at the waist while working? Are you further supporting the lower back by avoiding twisting and reaching while working?
8. Are you frequently shifting your body posture, and are you learning to lift by leaning back during stretching?
9. Are you using an asymmetric stance with the feet placed correctly, normal knee-lock position in the weight-bearing leg, and variations using a short and tall stool to provide protection for the back?

You should have answered yes to the above questions. If these tips don't help, check out continuing education providers that offer classes in body mechanics or related classes. Choose your course carefully. You do not want to replace one set of bad habits for another. One place you can locate classes is on NCBTMB's website: www.ncbtmb.com. You can also call (800) 296-0664 to find CEU providers in your area.

Remember that the human body is designed for movement and range of motion, not for the compressive forces required when giving a massage. Appropriate body mechanics must be maintained to provide adequate pressure throughout the massage. Body mechanics systems that are based on movement, such as dance and martial arts systems, are not designed for the delivery of compressive force required for massage. Learning to effectively use your knees and feet while working on a mat as part of your massage applications can allow you to rest your arms and hands. Some applications of shiatsu and Chinese massage systems incorporate these applications of pressure delivery.

A well-trained massage professional should be able to effectively provide five to six massage sessions a day, five days per week, without excessive fatigue or pain. If you are unable to maintain this type of work pace, your body mechanics is the most likely cause. Take action now so that you can have the career you desire.