Lauriann Greene gives advice for preventing work-related injuries     

Dear Lauriann,
I just graduated from massage school, and will start working at a massage clinic soon. One of my former teachers suggested that I start strength training and stretching regularly to prepare for the demands of my new career. I think if I were stronger, deep-tissue techniques would be easier to do. But what is the importance of stretching? Will it really help me prevent being injured by my work?

Dear Amy,
Strengthening and stretching are both important for massage therapists. Swedish and deep-tissue massage require a certain amount of strength and endurance on the part of the massage therapist. But an effective workout should include both strengthening and stretching. Stretching has a number of beneficial effects that help prevent injury. A strengthening routine will be more effective and less likely to cause injury if you stretch the muscles you have strengthened. To more fully understand the importance of stretching, it is helpful to understand what happens to your muscles when you massage, and the effect stretching has on those muscles.

When you massage, your muscles contract. They may contract to a greater extent if you lack strength or if you are emotionally tense. If you massage with overcontracted muscles for long periods of time without resting between massage sessions, the overworked muscles tend to stay in their contracted state even after you have finished the massage session. They become hypertonic, and circulation decreases in the muscle tissue. The decreased circulation makes the muscle tissue less pliable and more likely to tear. The constant level of tension leads to a buildup of lactic acid and other waste products, which causes pain and inhibits healing. The same situation can happen as a result of strengthening your muscles in your workouts: they remain contracted, circulation decreases, and waste products are not efficiently eliminated.

Intense workouts, or intense massage sessions, can cause micro-tearing of muscle tissue, leading to inflammation and the development of scar tissue. These micro-tears need to heal so they don't turn into more serious injuries. It is important to allow your muscles to relax so they can rest and restore themselves.

Stretching counteracts tension by lengthening contracted muscle tissue, and mechanically "pumps" lactic acid and other waste products out of the muscles. Once the contraction has been relaxed, normal circulation is restored, and the muscles can rest. If there has been micro-tearing due to overuse, stretching will help realign developing scar tissue to prevent adhesions from forming. Stretching allows the muscle to regain its full range of motion by lengthening muscle fibers that have become shortened by work or exercise.

Your posture can also lead to chronic muscle tension and shortening of muscle fibers. Massage therapists spend a great deal of their time doing strenuous work with their arms in front of their bodies. As a result, the muscles of the chest and the anterior shoulder get overworked, tight and shortened, while the muscles of the upper back get overstretched and weak.

This imbalance makes it impossible for the muscles to exert an even pull on the upper extremity (arms, hands, shoulder girdle) to help with its work. The resulting head-forward, chest-caved-in posture can also cause compression of the brachial plexus and cervical nerve impingement, setting the stage for upper-extremity injury. You can resolve this imbalance by stretching the front of the body, and strengthening the back of the body. Stretching the arms and hands is essential for massage therapists, since these parts of their bodies are the most overused.

Stretching also increases flexibility by lengthening contracted muscles and tendons. While flexibility is an important element of good health, it is less directly beneficial for massage therapists than the effects of stretching describe here.

One thing stretching does not do is warm up your muscles. Warming up refers to raising your body temperature and increasing circulation to get blood flowing into your muscle tissue. Since maintaining good circulation is an important component of injury prevention, you should warm up before any workout and before starting to massage. To warm up, do five minutes of aerobic exercise like brisk walking, running in place or skipping rope. For your stretches to be effective and safe, do them after you have warmed up. Stretching before warming up can cause injury, since cold muscle tissue is more likely to tear.

There are many different methods of stretching. No one method is better than the other - it's a matter of finding the one that works best for you.

The standard type of stretching that most people do is referred to as active stretching. This type of stretching involves taking your body into a pose that is designed to facilitate lengthening a particular muscle or group of muscles. The most effective stretches isolate one muscle, to give you greater control over the stretch. There is much disagreement among stretching experts on how long one should hold an active stretch. Somewhere between 30 and 60 seconds should give your muscles enough time to relax into the stretch. The best-known book of active stretches is Stretching, by Bob Anderson, which contains muscle-specific stretches and stretching routines created for particular sports. Another good resource on active stretching is SynerStretch, from Health for Life, which exists in both book and video formats.

Yoga is another type of active stretching that also includes meditation, breathing and self-awareness, each an important element in injury prevention. Recent studies have show youga to be more effective overall in treating carpal tunnel syndrome than using splints. ExTension, by Sam Dworkis, presents a yoga-based stretching program to relax, release and rejuvenate the body.

Passive stretching, which involves a second person who moves your body into stretches, can also be very beneficial. In a totally relaxed state, you can stretch farther than you can when you have to create the movement yourself. Your massage therapist can make passive stretching part of your session when you get bodywork. Swedish and deep-tissue massage also lengthen muscles, helping them relax and increasing blood flow to the tissues while removing waste products. Sport Stretch, by Michael J. Alter, describes passaive stretches. Another type of assisted stretching is described in Active Isolated Stretching, by Aaron L. Mattes.

Here are some stretching tips. 1) Be careful not to overdo your stretching. Forcing your muscles to stretch to the point of pain or discomfort can cause tearing of muscle tissue and injury. It's best to go just to the point where you feel the stretch and stay there. 2) Avoid bouncing in active stretching as the extent of each bounce is difficult to control, putting you at risk of overstretching the concerned muscle. 3) Make sure you take slow, deep, regular breaths as you stretch, to counteract tension and help you relax into the stretch. Breathe in through your nose, and out through your mouth. 4) Drinking lots of water is always a good idea, but it can also help in your stretching. Proper hydration aids flexibility, and helps relax the body.

More Helping the Healers

Lauriann Greene is a massage therapist and the author of Save Your Hands! Injury Prevention for Massage Therapists which is used by massage schools in North America and in five other countries; and by physical therapists, chiropractors, and other manual therapists to help prevent injury.  She has also taught "Save Your Hands" workshops in numerous locations across America.

Please note: This column is edited by a medical doctor to make every attempt to ensure medical accuracy of the answers given; however, the recommendations and techniques described in this column are meant as suggestions only, and are not intended to be a substitute for appropriate medical advice and treatment from your own qualified health care provider. Readers who experience any signs or symptoms of injury have the responsibility to seek professional medical advice and treatment.