Work-related musculoskeletal complaints in massage practitioners

Abstract

BACKGROUND:

Work-related musculoskeletal complaints (WMSCs) are induced or aggravated by work activities and/or work conditions.

OBJECTIVE:

The aim was to evaluate the impact of work as a massage practitioner, with a special emphasis on WMSCs.

METHODS:

Massage practitioners were invited to participate in the study through an advert in the rehabilitation medical clinics. The participants completed a self-administered questionnaire, collecting general data and questions about WMSCs.

RESULTS:

Thirty-seven subjects (88.09%) reported pain in at least one body part in the last 4 weeks. The most common WMSCs was pain in the neck region (69.04%), followed by pain in the shoulder region (54.76%), upper back (52.38%), lower back (40.48%), wrist-hand (33.33%) and elbow (21.43%). The massage practitioners aged between 21 and 30 years old reported significantly more frequently WMSCs localized in neck, shoulders, wrist-hand, upper back and lower back.

CONCLUSIONS:

This study shows that WMSCs are widely reported among massage practitioners. The most common complaints were reported in the neck and shoulder regions, especially in younger massage practitioners.

Keywords

Musculoskeletal pain health workers massage therapist

1 Introduction

Work-related musculoskeletal complaints and disorders (WMSCs) are induced or aggravated by work activities and/or work conditions, leading to pain, functional impairments and disability [1]. The prevalence of WMSCs is relatively high among healthcare professionals. WMSCs may negatively impact the quality of life, may influence activity for long periods of time that lead to absenteeism, decreased productivity, increased health care needs, disability, and worker’s compensation costs [2 –4]. In healthcare professionals, strain lesions are the predominant occupational musculoskeletal injuries, muscle and ligaments being overloaded by indirect trauma, with younger workers being more affected [2]. The healthcare professionals involved in physical and intimate patient contact, with higher physical demanding tasks were reported to be a significantly higher risk of developing WMSCs [5]. Numerous studies evaluated the prevalence of WMSCs in nurses, nurse assistants, sonographers, surgeons, dentists and dental technicians [6 –16]. Studies have demonstrated that physical therapists are also at high risk of developing WMSCs, with lower back, upper back, neck, shoulder, wrists and hand as main localization of these complaints [17 –21]. Mobilizations, manipulation and other hands-on techniques, lifting or transferring dependent patients, uncomfortable postures, repetitive and maintained activities were some of the risk factors identified in physical therapists [17 , 22].

Some of the above-mentioned risk factors are common also for massage practitioners. The sustained and static effort performed during different hands-on technique, the awkward and stressful working postures and the repetitive and forceful use of upper limbs can cause a cumulative external load that will exceed the tissues’ internal tolerance and will cause musculoskeletal injuries (cumulative trauma load-tolerance model) [23].

There are only a few studies that analyze the WMSCs among massage practitioners. Therefore, the aim of the present study was to evaluate the impact of work as a massage practitioner, with special emphasis on WMSCs.

2 Materials and methods

2.1 Participants

Massage practitioners were invited to participate in this study, by advertising in rehabilitation medical clinics located in Timisoara, Romania. Eligibility criteria were [1] full-time massage practitioners; [2] with more than 1 year of experience; [3] performing classical massage from a standing posture on clients lying prone on a standard massage table; [4] no surgeries in the last 6 months; [5] no clinically diagnosed inflammatory musculoskeletal diseases.

Participation in the study was voluntary. Participants who agreed to participate and met the inclusion criteria read and signed the informed consent form [24]. The study was carried out in accordance with the Declaration of Helsinki and was approved by the local Ethics Committee (173/03.10.2019).

2.2 Assessments

The participants completed a two-part self-ad-ministered questionnaire. The first part of the questionnaire collected general data, like age, gender, weight, height, years of practice, number of daily treated patients, daily working hours, while the second part included questions about the WMSCs. A body diagram was used to help the respondents indicate the affected body parts. If a subject answered with “yes” on the question “Have you had pain in your neck/ shoulder/ elbow/ wrist-hand/ upper back/ low back in the last 4 weeks?”, then the subject had to answer the questions regarding the pain severity on a 10-point visual analogue scale (VAS) and duration (a single item from the questionnaire addressed the pain duration). The questions about WMSCs were adapted from the Nordic Musculoskeletal Questionnaire, a validated, repeatable sensitive and useful screening tool [25].

2.3 Statistical analysis

The collected data were analyzed using the MedCalc Statistical software version 19.2.1 (MedCalc Software Ltd, Ostend, Belgium). Descriptive statistics (means and standard deviation, number and percentage) were calculated. The relationship between WMSCs and age, sex, years of experience, daily working hours and number of treated patients was evaluated using Chi-square analysis. In order to compare continuous variables based on the affected regions, a One-way ANOVA with Student-Newman-Keuls post-hoc tests were performed. The significance level was set at p < 0.05.

3 Results

Forty-two massage therapists (45.2% males) aged 24–60 years met the inclusion criteria and agreed to participate in the study. General characteristics of the study sample are presented in Table 1.

Table 1
General characteristics

Variable

Age, years (mean±SD) 35.5±12

Sex

Male, n (%) 19 (45.2)

Female, n (%) 23 (54.8)

Weight, kg (mean±SD) 75.91±14.88

Heigth, kg (mean±SD) 174.91±2.51

BMI, kg/m² (mean±SD) 24.56±2.51

Dominant hand

Right, n (%) 37 (88.1)

Left, n (%) 5 (11.9

Experience, years (mean±SD) 5.83±4.74

Number of daily working hours (mean±SD) 4.59±2.08

Number of patients treated daily (mean±SD) 4.71±2.29

Pain > 30 days, n (%) 13 (31)

Variable
Age, years (mean±SD)	35.5±12
Sex
Male, n (%)	19 (45.2)
Female, n (%)	23 (54.8)
Weight, kg (mean±SD)	75.91±14.88
Heigth, kg (mean±SD)	174.91±2.51
BMI, kg/m² (mean±SD)	24.56±2.51
Dominant hand
Right, n (%)	37 (88.1)
Left, n (%)	5 (11.9
Experience, years (mean±SD)	5.83±4.74
Number of daily working hours (mean±SD)	4.59±2.08
Number of patients treated daily (mean±SD)	4.71±2.29
Pain > 30 days, n (%)	13 (31)

BMI – body mass index

The mean age of therapists was 35.5 years with an average of 4.59±2.08 working hours/day. Furthermore, most participants had 5 years of clinical experience or less (n = 26, 61.9%), 11 participants (26.2%) between 6 and 10 years of experience, and 5 participants (11.9%) between 15 and 20 years of experience. Thirty-seven subjects (88.09%) reported that they have experienced pain in at least one body part in the last 4 weeks.

The most common WMSCs was pain in the neck region (n = 29, 69.04%), followed by pain in the shoulder region (n = 23, 54.76%), upper back (n = 22, 52.38%), lower back (n = 17, 40.48%), wrist-hand (n = 14, 33.33%) and elbow (n = 9, 21.43%). Most of the participant have reported WMSCs in more than one body part –21.4% (n = 9) have reported WMSCs in 2 regions, 38.1% (n = 16) in 3 regions, 4.8% (n = 2) in four regions and 7.1% (n = 3) for 5 and 6 regions, respectively. The pain and subjects‘ characteristics based on the affected body part are presented in Table 2.

Table 2

Prevalence of WMSCs, pain and subjects’ characteristics

	Neck pain		Shoulder pain		Elbow pain		Wrist-hand pain		Upper back pain		Low back pain
	(n = 29)		(n = 23)		(n = 9)		(n = 14)		(n = 22)		(n = 17)
		p ^*		p ^*		p ^*		p ^*		p ^*		p ^*
Sex
Male, n (%)	10 (34.48)	0.09	10 (43.48)	0.53	5 (55.56)	0.73	2 (14.29)	0.007	10 (45.45)	0.66	7 (41.18)	0.46
Female, n (%)	19 (65.52)		13 (56.52)		4 (44.44)		12 (85.71)		12 (54.55)		10 (58.82)
Age, years (mean±SD)	33.21±11.98 ^**		41.39±13.55^**		44.33±10		31.5±10.81		35.27±13.06		31.41±9.75
Age group
21– 30, n (%)	20 (68.97)	0.0002	9 (39.13)	0.04	0 (0)	0.31	11 (78.57)	0.03	14 (63.64)	0.006	11 (64.7)	0.02
31– 40, n (%)	3 (10.34)		1 (4.35)		3 (33.33)		0 (0)		2 (9.09)		3 (17.65)
41– 50, n (%)	0		4 (17.39)		0 (0)		0 (0)		0 (0)		0 (0)
51– 60, n (%)	6 (20.69)		9 (39.13)		6 (66.67)		3 (21.43)		6 (27.27)		3 (17.65)
Dominant hand
Right, n (%)	27 (93.1)	< 0.0001	22 (95.65)	< 0.0001	6 (66.67)	0.317	12 (85.71)	0.007	18 (81.82)	0.002	15 (88.24)	0.001
Left, n (%)	2 (6.9)		1 (4.35)		3 (33.33)		2 (14.29)		4 (18.18)		2 (11.76)
VAS (mean±SD)	4.45±1.84		4.36±2.32		4.33±2.78		3.35±1.86		3.52±1.04		4±2.37
Experience, years
(mean±SD)	3.86±1.87 ^§,^#		7.09±6.01 ^§		8.33±5.89 ^#		3.07±1.64 ^§,^#		4.13±1.78 ^§,^#		3.41±1.77 ^§,^#
1– 5 years, n (%)	23 (79.31)	0.001	12 (52.17)	0.154	3 (33.33)		14	NA	17 (77.27)	0.01	14 (82.35)	0.007
6– 10 years, n (%)	6 (20.69)		6 (26.09)		3 (33.33)		0		5 (22.73)		3 (17.65)
11– 15 years, n (%)	0		0		0		0		0		0
16– 20 years, n (%)	0		5 (21.74)		3 (33.33)		0		0		0
Working hour per day
(mean±SD)	4.38±2.13		4.13±2.18		5.33±0.5		5.42±1.6		4.04±1.94		5.18±1.98
1– 3 hours/day, n (%)	12 (41.38)	0.343	8 (34.78)	0.07	0	NA	3 (21.43)	0.605	9 (40.91)	0.141	6 (35.29)	0.942
4– 6 hours/day, n (%)	11 (37.93)		12 (52.17)		9		5 (35.71)		10 (45.45)		5 (29.42)
7– 8 hours/day, n (%)	6 (20.69)		3 (13.05)		0		6 (42.86)		3 (13.64)		6 (35.29)
Number of patients treated per day (mean±SD)	4.86±2.42		4.13±1.6		4.33±1		4.5±1.83		4.27±1.35		4.74±2.75
Pain > 30 days, n (%)	8 (27.58)		5 (21.74)		0 (0)		8 (57.14)		8 (36.36)		8 (47.05)

^*Chi-square tests; ^**, §,^#p < 0.05 (One-way ANOVA, post-hoc comparisons); VAS – visual analogue scale for pain.

Gender differences were found only for wrist-hand pain, with a higher percentage of female massage practitioners reporting WMSCs in this area ( $χ_{(1)}^{2}$ = 7.143, p = 0.007).

There was a statistically significant difference in age according to the affected regions [F(5,108) =3.012, p = 0.014]. Post-hoc comparisons revealed that subjects with WMSCs in the shoulder region were significantly older than subjects reporting neck WMSCs (p < 0.05). The massage practitioners aged between 21 and 30 years old reported significantly more frequently WMSCs localized in neck ( $χ_{(2}^{2}$ ) = 17.034, p = 0.0002), shoulders ( $χ_{(3) =}^{2}$ 8.13, p = 0.043), wrist-hand ( $χ_{(1)}^{2}$ = 4.571, p = 0.032), upper back ( $χ_{(2)}^{2}$ = 10.182, p = 0.006) and lower back ( $χ_{(2)}^{2}$ = 7.529, p = 0.023). Elbow pain was more common in the older age group (51-60 years), without a significant correlation.

The number of years of experience were significantly correlated with neck pain ( $χ_{(1)}^{2}$ = 9.966, p = 0.001), upper back pain ( $χ_{(1)}^{2}$ = 6.545, p = 0.01) and lower back pain ( $χ_{(1)}^{2}$ = 7.118, p = 0.007), with those with less than 5 years of experience experiencing more WMSCs. There was a statistically significant difference in years of experience according to the affected regions [F(5,108) = 5.596, p < 0.001]. Post-hoc comparisons revealed that massage practitioners with shoulder and elbow WMSCs had significant more years of experience compared to those with neck, wrist and hand, dorsal and lumbar WMSCs (p < 0.05).

4 Discussion

Although there are many studies on WMSCs prevalence in physical therapists, there is little information about musculoskeletal complaints among massage practitioners. Massage therapists are often at risk for developing WMSCs because of repetitive movements, maintaining long periods of trunk and neck flexion, as well as prolonged and incorrect postures in their practices.

The majority (88.09%) of the assessed massage practitioners reported that they have experienced WMSCs in at least one body part. The most affected region was the neck, followed by the shoulder, upper back, lower back, wrist-hand complex and elbow.

Our results were in accordance with the results reported by Albert et al. [26]. In their study, they found that musculoskeletal pain and discomfort in the low back, shoulders, neck, wrists and thumbs were frequently experienced by Canadian massage therapists. They found that the prevalence of low back pain was higher in younger massage therapists, with less years of experience. In our study, we also found that WMSCs in neck, shoulders, wrist-hand, upper and lower back were more frequent in younger massage practitioners (age group 21–30 years). We found gender differences only in wrist-hand pain, while Albert et al. reported gender differences in neck pain. In both studies, the females massage practitioners were more affected. Similar with the results reported by Albert et al, we found that therapists with less years of experience (1–5 years) reported musculoskeletal pain in the neck, upper and low back. A possible explanation for this result may be that young therapists have not been accurate trained or do not know the prevention or protection measures to avoid musculoskeletal conditions. Training is required for therapists to be informed and aware about ergonomic problems that can occur at their workplaces. On the other hand, they should be encouraged to report early their complaints in order to prevent or reduce the progression of symptoms or the development of serious musculoskeletal injuries.

According to Da Costa [27] it is important to identify the risk factors significantly associated with the high prevalence of WMSCs. Among these factors are the biomechanical risk factors, such as excessive repetition, incorrect postures, and heavy lifting.

Occupational therapy manuals instruct all therapists of the importance of proper working conditions. Thus, the width and height of the massage table determine the posture of the one who practices the massage. Albert et al. [28] established that the proper table height for the massage therapists should be 40–43% of their standing height which would be between their fingertips and wrists. They found that the trunk posture was divided 50 : 50 between the neutral and mild posture, while the shoulder and neck were in neutral postures for 30 and 40 percent of the time. In our study, all participants reported using standard massage tables, not being able to specify if they have adjusted the table height according to their standing height.

Page [29] reported WMSCs in the lower back, shoulder, neck and wrist or thumb of the evaluated licensed massage therapists (mean age 38.5 years). The wrist and thumb pain were the most common WMSCs and the main cause of lost-work and leisure time (30% and 35%, respectively). No gender or years of experience correlations were studied, instead Page found that more than 70% used in their daily routine moderate and deep pressure techniques.

In another cross-sectional study, Jang et al. [30] reported that in a sample of 161 visually impaired massage practitioners (aged 37.7±10.7 years, with 11.3±10.5 years of work experience in massage) the fingers and thumbs were most frequently affected, followed by shoulder, wrist, elbow and forearm, upper and lower back. Their results were not in accordance with ours, which showed a higher prevalence of neck, shoulder upper and lower back WMSCs. Younger massage practitioners (aged 31–45 years) were more likely to report neck and upper- back symptoms than those aged > 45 years in the study by Jang et al.

Maintaining a bending forward posture, for a longer period of time, treating a larger number of patients per day were some of the factors associated with lower back WMSC in a sample of 50 female masseuse aged 18–35 years [31]. The odd posture, length of work and age were also significant correlated with the incidence of work-related musculoskeletal disorders in massage therapists, with hands, shoulders and lower back being the most frequent affected area [32]. Jang et al. [30] also reported that spending more than 4 hours/ day in direct contact with clients would increase the prevalence of finger pain in massage practitioners. Treating a large number of patients dailyhas been found by Cromie et al. [17] to increase the risk of thumb, elbow, shoulder, neck and wrist and hand symptoms in physical therapists. Our results did not support a significant relationship between working hours per day or number of patients treated per day and the presence of pain in any regions. Rozenfeld et al. [33] found that the number of hours per week performing manual treatments was associated with an increased risk of wrist/thumb symptoms and a decreased risk of lower back complaints in physical therapists.

Buck et al. [34] found that muscular and postural demands in massage practitioners were depended of the performed massage techniques and whether the massage was performed with the patients lying on the table or sitting on a massage chair. When therapists used the massage table, the lumbar erector spinae showed higher mean activation that was related to the posture (more time spent in trunk flexion). When performing muscle squeezes on the patients’ upper trapezius, a significant higher activation was seen in the therapists’ anterior deltoid. Although the authors could not conclude on possible harm using their findings, longer activity duration (a higher number of patients treated daily, no breaks) could lead to muscle fatigue and increase the risk of injury [34].

It is important that massage therapists are educated on personal health including the use of proper work conditions and techniques that involves accurate postures to reduce the cumulative exposure to the neck region, shoulder, upper back, lower back and hands.

WMSCs are widely reported in literature among physical therapists, with a lifetime prevalence varying between 55–91% and a one-year prevalence ranging 40–91% [19]. The lower back is reported to be the most common complaint in physical therapist [19 , 35]. As observed in our study, the young (under 30 years old) and less experienced physical therapists are also at high risk of developing WMSCs [19, 22]. The possible explanation could be the experience and practice behaviors, with the younger therapists implied in more physically demanding clinical areas. Manual therapy and a large number of treated patients were the most frequent causes for thumb and hands WMSCs in physical therapists [22].

The study presented here has some limitations. The first limitation is the small sample size, being a single-center study (Timisoara, Romania). Our data were self-reported and therefore the results are subjective and less accurate than objective measurements. Moreover, our questionnaire has not been validated. However, musculoskeletal disorders are self-reported conditions that often occur without objective clinical findings. Further studies are needed to assess not only the risk factors associated with the presence of WMSCs (working conditions, posture, lifestyle factors, physical demands and also psychosocial factors), but also the prevention strategies.

5 Conclusions

This study shows that WMSCs are widely reported among massage practitioners. The most common complaints were reported in the neck and shoulder regions, especially in younger massage practitioners. There is a significant need for the massage therapists to be educated on proper work conditions and techniques that involves accurate postures to reduce the cumulative exposure to the neck region, shoulder, upper back, lower back and hands.

Conflict of interest

The authors declare no conflict of interests.

Funding

This research received no external funding.

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