Occupational Related Injuries in Shiatsu Practitioners and Students
In June 2002 I had an epiphany, a moment of realisation if you like. Unfortunately my realisation was that I had been damaging myself. It came at the end of a day working at a Complementary Health Fair. Over the course of the day I had carried out about 6 Shiatsu treatments, a combination of full treatments on a futon and shorter sitting treatments in a chair. I’d been busy but had managed to find time to relax between treatments. When I got home I knew there was a problem, there was an aching discomfort in the backs of my hands and my thumbs were ‘buzzing’ gently. These weren’t new sensations. I’d felt them before, though not to the same degree and had just put it down to muscular tiredness. But this day was different, I had finally realised that there was something wrong. Something about the way I was doing Shiatsu was not just making my hands tired, it was damaging them. I immediately realised that I had to stop treating and find out what it was that I was doing wrong. Over the following months I searched all the relevant literature I could find in order to better understand and remedy my predicament. During the course of this research I found that many massage therapists have had similar problems, but could find no relevant literature regarding Shiatsu practitioners. Whilst I found much useful information on what do about such problems, there was nothing to tell me how common these problems are amongst Shiatsu practitioners nor how other Shiatsu practitioners may have dealt with them.
So, in Spring 2003, following discussions with the then Chair of the Shiatsu Society, I devised a questionnaire to gather information from Shiatsu practitioners and students. I asked them about any ill health they had suffered that was related to their practice of Shiatsu. The questionnaire was sent to everyone on the Society’s email circulation list and also to the members of an online discussion forum on Shiatsu1. The members of the discussion forum are all practitioners or students of Shiatsu. Of a total of 1125 practitioners and students who received the questionnaire, 102 responded. I analysed the questionnaires that were returned, looking at the number and nature of any problems, and any other factors that might promote or prevent such problems. The findings of this analysis are presented below.
Number of Injuries
51% of respondents reported that they believed they had an injury which had been caused by practising Shiatsu. A further 13% considered that Shiatsu had exacerbated a pre-existing injury. One person (ie. 1%) was unsure and 35% considered that they had not been injured.
At first glance the figures on rates of injury seem very high indeed. But what do they mean? Can we use them to predict what is happening for other shiatsu practitioners and students? The following section may seem rather heavy with statistics but this is necessary to get a clear understanding of how widespread this problem is.
Let us assume for a moment that the people who responded did so on an entirely random basis. Statistically speaking the 102 respondents would be an unbiased sample of the whole population. It might seem reasonable to simply scale up these percentages to work out many members of the Society are affected by such injuries (ie. 51% injuries and 13% exacerbations). However, even on this random basis, there may be some natural variability in the responses. Statistically speaking, we can say it is highly likely (ie. we are 99% certain) that the rate of injury is in the range 39-65% and the rate of exacerbation is in the range 4-22%.
Remember though that we made an assumption here – that the responses were at random, or to put it another way – whether someone was injured or not did not affect their decision to reply. It seems more reasonable to assume that the responses were biased, or ‘weighted’ – ie. those people who have experienced some injury were more motivated to reply than those who are not injured. Perhaps all of the people who have been injured actually replied, along with only a very few of those who are not injured. If this were the case then we can easily calculate the injury and exacerbation rates to be 5% and 1% respectively.
Neither of these extremities is likely. For one thing, I personally know of practitioners on the email distribution list who have been injured and yet did not reply to the questionnaire. I also know one former practitioner who is no longer on the distribution list and in fact no longer practices Shiatsu due to injuries incurred apparently as a result of her professional practice. How many others are there in the same situation? On the other hand it does seem reasonable to assume that injured people were more motivated to fill in the questionnaire, so that would move the weighting in the other direction.
So we now have upper and lower limits for the rate of injury, and reasons for doubting that the real figure lies at either of these extremes. But we can be extremely confident that the rate of injury lies between 5% and 65%, and the rate of exacerbation between 1% and 22%.
To conclude this more simply: we can be very confident that at least 1 in 20 practitioners or students believe they have been injured by their practice of shiatsu. The real figure could, however, be much higher.
Average Number of Treatments
The number of treatments in an average week varied from 1 to 25. There were several respondents who carry out upwards of 20 treatments per week, but some of these appeared to be other sorts of therapy (eg. Reiki, massage) or were shorter (30 minutes or less) treatments.
Respondents with injuries (including pre-existing exacerbated injuries) carried out an average of 6.8 treatments per week, compared with 5.5 treatments by uninjured respondents. Whilst this may suggest that there is a correlation between injury and the number of treatments carried out per week, technically we cannot be completely confident of this. In other words, the correlation is not statistically significant2.
Variation in workload
Almost all respondents had workloads which varied by somewhere between 1 and 10 treatments per week. There were 10 respondents whose workload could vary by between 10 and 34 treatments (although some of these may be quite short).
Of these 10 respondents, 8 believed they have been injured as a result of practicing Shiatsu and the other 2 believed that practicing Shiatsu has exacerbated existing injuries.
The workload of respondents with injuries (including pre-existing exacerbated injuries) varied by an average of 6 treatments per week, compared with an average variation of 5 treatments for uninjured respondents.
Whilst these two factors may suggest that there is a correlation between injury and variation in workload, neither is statistically significant.
Maximum number of treatments in one day
The maximum number of treatments carried out in 1 day was 12.
On average the maximum number of treatments carried out in one day was almost exactly the same for injured and uninjured respondents.
Age
The ages of respondents varied between 24 and 71.
There is no evidence to suggest that age may be related to the likelihood of injury. Neither does there seem to be a particular age at which injury is more likely to occur.
Minimum Interval between treatments
There is considerable variation in the minimum interval respondents leave between consecutive treatments, ranging from no gap at all to several hours. Almost a third of respondents do not leave any time between consecutive treatments.
On average, there was little difference in the interval between appointments for injured (14 minutes) and uninjured (14½ minutes) respondents.
Other work
Outside of practicing Shiatsu, respondents had a range of other jobs. These were categorised as follows:
- Sedentary (eg. office work)
- Physical
- Therapeutic (ie. other therapies)
- Teaching Shiatsu
- Musician
- None
Some respondents reported doing combinations of two of the above, alongside their Shiatsu practice. By far the biggest category was the sedentary one.
There is no evidence of a link between the type of other work that respondents do and their likelihood of injury.
Physical Activity
There is considerable variety in the physical activities (outside of Shiatsu) that respondents are involved in. The following list shows the main activities, roughly in order of popularity:
- Yoga
- Swimming
- Walking
- Martial arts (including Tai Chi)
- Cycling
- Gym/aerobics
- Qi gong
- Running
- Dancing
- Gardening
- Water sports
13 respondents considered they took part in no demanding physical activity at all. There was insufficient data to say whether there was any correlation between risk of injury and the type of physical activity that respondents participate in.
Activities which place demands on the hands
By far the most common such activity is the use of computers (most considered the act of typing demanding but one found using a mouse more demanding). Other activities listed include playing a musical instrument, housework, sports, writing, gardening and various manual tasks (eg. DIY).
Location of Problems
This section considers both problems believed to be caused by the practice of Shiatsu and problems believed to be exacerbated by practising Shiatsu.
There were 28 reports of upper limb problems (including shoulder), 20 lower limb and 18 torso (consisting of back and, in one case, neck). Some respondents reported multiple problems involving one or more of these categories. At first glance it would appear that upper limb problems are the most common, but this cannot be confirmed statistically. It may in fact be that injuries are evenly distributed between these three categories: upper limb, lower limb and torso. 11 of these respondents actually reported a variety of multiple problems.
There were a further 2 reports of systemic or other specific problems. These consisted of fatigue, headaches and reduced cognitive functioning.
17 respondents reported back problems. Of these, 9 reported problems with the lower back and 2 with the thoracic region, but 6 respondents were no more specific than indicating that it was merely a back problem. Whilst this is suggestive that lower back problems are more common (than upper/mid back) there is insufficient data to confirm this statistically.
The lower limb problems were confined to the knees, apart from 1 person with hip problems. Roughly equal numbers of people reported either unilateral or bilateral problems (9 reported problems with one knee, 11 with both).
The largest category consisted of upper limb problems. Again, roughly equal numbers of people reported either unilateral or bilateral problems (19 reported bilateral problems compared to 16 unilateral). The majority of these problems affected the wrists and/or thumbs.
For both upper and lower limb problems, it is not possible to say whether bilateral or unilateral problems are statistically more common.
Types of Problems
On examining the questionnaire replies it was possible to say something about how the problems change over time. For the purposes of analysis they were divided into the following categories: single episode, sporadic, ongoing and chronic. Ongoing problems were defined as those that were currently affecting the respondent but could not, at this point in time, be definitely assigned to one of the other categories. There was some inevitable degree of subjectivity in the way that these categories were assigned. It was not possible, however, to systematically say anything about the severity of the problems encountered. It is clear though that they range from minor and transient discomfort to extremely painful and debilitating.
Some people were very specific about the diagnosis of the problem, eg. osteo-arthritis of the hip joint, or ulnar nerve compression at the wrist, but many have not had a medical diagnosis and so the nature of the problems were less precise.
Looking at exacerbations of pre-existing injuries, about half of these had become chronic, at least in part – so the respondents believed - because of the person’s practice of shiatsu.
Ignoring the exacerbated injuries for a moment, it appears that the sporadic problems are more likely than any of the other categories (chronic, ongoing or single episode) with the others being roughly equally likely. We cannot say this with any degree of statistical confidence however.
When do problems occur
Firstly it should be noted that I have made the assumption that all practitioners spent 3 years as a student before qualifying. Whilst I am confident that this is true for most practitioners it may not be the case for some of the longer-standing practitioners, or indeed those who ‘dabbled’ with shiatsu for several years before enrolling on an accredited 3 year course, or those who had a ‘year out’. That said, there was an evident pattern showing when injuries are most likely to occur during a person’s exposure to studying or practising shiatsu. The very first year showed the highest rate (9 respondents) of problems with 4 the following year then a very steady stream of 2 or 3 each year thereafter. So it would appear that the main ‘danger’ period is while a person is studying, specifically during the first two years. However, as the numbers are quite small it is impossible to confirm this statistically.
Symptoms
There were very clear categories of symptoms reported. These were, listed in order of frequency: | Pain | 52 |
| Stiffness | 15 |
| Swelling | 7 |
| Fatigue/tiredness | 5 |
| Limited ROM | 5 |
| Weakness | 5 |
| Feeling of heat | 2 |
| Tingling | 2 |
| Numbness | 2 |
| Crepitus | 2 |
| Discomfort | 1 |
| Palpitations | 1 |
| Reduced immunity | 1 |
| Cognitive problems | 1 |
Out of the 63 different problems where the respondents actually gave some indication of their symptoms (not everybody did) 52 of them involved pain. In other words, most problems involve some degree of pain, although it is not possible to comment on the severity of pain experienced.
Many of the symptoms were reported in ‘constellations’ of several different symptoms. These constellations always involved pain and typically consisted of 2 or 3 different symptoms in total. The most common constellation was the grouping of pain and stiffness, being reported 11 times on its own, plus several more times as part of larger constellations.
A number of symptoms were notable in that they were never reported on their own, but always as part of a constellation. Of particular note here were 2 of the symptoms from Group 3 above – weakness and limited ROM.
The majority of these symptoms are clearly related to the musculoskeletal system, with the possibility of some neurological involvement.
How did the practitioner/student deal with the problem
Of the 56 responses to this question, the majority (38) indicated that the practitioner/student continued treating whilst injured. 6 people justified they’re reasoning for continuing to treat, using the following reasons:
- Injury only minor (2 respondents)
- Injury only becomes apparent after finishing treatment
- Injury only apparent when doing a specific movement
- Problem only apparent during the last treatment of the day
- “Its never stopped me finishing a treatment”
A further 2 people reported that they initially continued treating but only stopped after several weeks when the problems worsened.
10 people continued treating, but modified their techniques to take their injury/problem into account (2 of these changed to using a treatment couch/table).
Onset
The onset of injury was classified as either sudden or gradual. Not all injured respondents answered the question regarding onset, and some answers could not be matched to either category. Gradual injuries appeared to be almost twice as common as sudden (30 gradual, 17 sudden). Whilst suggestive that gradual onset is more common than sudden onset, this cannot be demonstrated statistically. Whether the injury was believed to be shiatsu related or an exacerbation of an existing injury did not appear to make a difference to the nature of the onset. Neither did there appear to be a correlation between the nature of onset and the location of the injury.
Respondents who had suffered some injury or health problem had a variety of thoughts on why their problems occurred. These reasons can be split into several categories:
1. The physical movements of shiatsu itself:
- Performing techniques incorrectly, ie. bending or otherwise having poor posture and/or mechanics.
- Kneeling
- Overuse
- Excessive weight-bearing
- Being ungrounded
- Hyper-extension of joints (wrist)
- Hyper-flexion of joints (knee)
- Muscular tension
- Repetition of certain movements/postures
- Lack of strength
- Inexperience
2. Systemic, lifestyle or energetic issues: - Age
- Congenital problems
- Stress
- Tension
- Pre-existing injuries
- Giving but not receiving
- Not recognising own limitations
- Not looking after oneself
- Tiredness
- Weak kidneys
3. Other: - One person reported not warming up properly before treating
- One person was practicing on a mat that was too thin – the problem improved considerably when they started working on an appropriate surface
- One person regarded injury as an occupational hazard for Shiatsu practitioners
Therapeutic Intervention
There were 37 instances of respondents seeking some sort of intervention to help with their health problems and 16 in which no help was sought. Of interest were the 16 cases of injury where no help was sought. Various reasons were given, or appeared to be apparent, for this seeming lack of concern. They included such factors as:
- The problem was only mild
- The problem was sporadic or only a single episode
- Shiatsu technique was modified and the problem resolved
Of those respondents who did seek some intervention nearly all (36 of 37) used some form of complementary medicine, 6 of whom also sought had some form of orthodox medicine and one person sought orthodox intervention only. Given the relatively small number of respondents and the large variety in health problems noted and different interventions used it was not possible to say anything specific about the usefulness of specific forms of intervention. However, in the majority (28) of cases, the respondents found their particular interventions either moderately or very useful. A further 6 found the intervention slightly helpful and only one found it not at all helpful. The types of intervention used included the following: - Shiatsu/acupressure (either from someone else or self-administered)
- Various forms of massage
- Acupuncture
- Homeopathy
- Chiropractic
- Magnets
- Essential oils & other creams
- Osteopathy
- Reiki
- Moxibustion
- Yoga
- Qi gong
- Spiritual healing
- Meditation
- Oriental herbal medicine
- Rest
- Heat
- Cold
- Hydrotherapy
- Physiotherapy
- Anti-inflammatory medication
- Pain-relieving medication
Measures taken once injured
Once an injury or health problem occurred most respondents (49 out of 52) employed a range of strategies to prevent reoccurrence of the same problem. For the majority of people (35) who replied to this question these strategies proved to be moderately or largely successful in reducing their symptoms. 9 found they returned to completely to a state of good health and only 3 had improvement of a minimal nature.
Unfortunately for 3 respondents the only way they found to gain symptomatic relief was to cease practicing shiatsu, either permanently or on a long-term basis. Even then, none of them experienced a complete cessation of their symptoms, although one of these cases was admittedly a recent, acute problem.
The strategies employed to prevent reoccurrence fall into 3 broad categories:
1. Changing the way Shiatsu is carried out. This was done in a variety of ways:
- Avoiding certain techniques that cause/aggravate symptoms and/or employing different techniques to those which are being avoided (11 respondents)
- Modifying techniques so that they do not aggravate symptoms (5) eg. avoiding the use of muscular strength, working more energetically than physically
- Improving posture (7)
- Working from the hara / ensuring better use of bodyweight (2)
- Working on a treatment couch or table (3)
2. Changing the frequency of treatments - Carrying out less treatments
- Leaving larger intervals between treatments
3. Auxiliary practices. Some of these practices would be done routinely, eg. on a daily basis, or could be seen as part of the treatment process, ie. they would be performed immediately before or after treatment, or between consecutive treatments. The practises included: - Receiving shiatsu
- Do-in
- Qi gong T
- ai Chi
- Yoga
- Makko ho
- Rest
- Stretching
- Alexander technique
- Meditation
- Visualisation
- ‘Warming up’
Prevention
Of the 35 respondents who had not suffered any health problems which they attribute to Shiatsu only 4 confessed to not taking any measures to prevent injury. From the other 31 uninjured respondents several themes emerged:
- The use of exercises to warm-up before treating and/or to cool down after treatment. These exercises mostly fall into the following activities: stretching, qi gong, do-in & makko-ho.
- Some use of exercise generally to stay healthy. This was mostly likely to be one of the above forms of exercise, or some sort of strengthening exercise.
- Focussing on correct alignment whilst treating.
- Focussing on correct posture whilst treating.
- Working on a thick, large mat (or in one case a couch) to protect the knees.
Further Comments
This space was provided on the questionnaire to give respondents an opportunity to make any points that they felt they had not been able to cover sufficiently already. Naturally then, it is difficult to categorise these comments. However, there were several themes that appeared more than once, here and in other parts of the questionnaire:
- A belief that practitioners probably do not do enough to look after their own health, ignoring this to focus on the needs of their clients instead.
- A concern that very little (if anything) is taught about the likelihood and prevention of injury whilst training.
- A belief that some areas of the body are more prone to injury, ie. wrists/hands, backs & knees.
- A belief that Shiatsu can be very beneficial to the practitioner as well as the client.
Conclusions
It should be understood that the sample size (102 people) is relatively small, especially given the large number of different possible factors that may have an affect on a practioner/student’s well-being. This means that it is difficult to draw statistically sound conclusions from the data. It also means that just because something could not be demonstrated statistically does not mean its not true, it may just be that some patterns will only emerge when enough people are polled. However, it is possible to say the following conclusions.
Incidence of injury
- At least 1 in 20 practitioners/students believe that practicing Shiatsu has damaged their health in some way. The real figure may be somewhat higher.
- A smaller number of practitioners/students believe that practising Shiatsu has exacerbated health problems that had other causes.
Nature of injuries - Almost all of the health problems reported were musculo-skeletal in nature.
- The most frequently injured parts of the body appear to be the knees, wrists, thumbs and lower back.
- There appears to be a roughly equal chance of injuries being either bilateral or unilateral.
- Upper-limb problems may be more frequent than torso or lower-limb problems.
- There appeared to be more sporadic than chronic health problems reported.
- The most common symptoms of injury are pain, stiffness, swelling, tiredness, limited range of movement and weakness. Most problems involve some degree of pain or discomfort.
- It may be more likely for the onset of health problems to be gradual rather than sudden.
- A variety of reasons were given as to why practitioners/students thought that their health problems had occurred.
Risk factors - It may be that doing more treatments per week is more likely to lead to injury.
- It may be that a greater variation in workload is more likely to lead to injury.
- The greatest risk of an injury first occurring appears to be during the first year or two’s involvement in Shiatsu. Thereafter the length of time practising does not appear to affect the degree of risk.
Reactions to injury - The majority of injured practitioners/student continued to treat clients whilst actually injured.
- The majority of injured practitioners/students sought some form of therapeutic intervention and most found it helpful to one degree or another.
- The majority of injured practitioners/students experienced significant improvement in their health problems but few of these experienced total recovery.
- Some injured practitioners/students were forced to retire from practising Shiatsu but still did not experience total recovery.
- Most injured practitioners/students pursued one or more of the following strategies to prevent a recurrence of their health problems i) modifying the way they do Shiatsu, ii) changing the frequency of treatments, iii) following a supplementary exercise regime of some sort.
Prevention - Of the 35 respondents who had not suffered any health problems 31 took measures to prevent injury. These included such strategies as ensuring correct posture and alignment whilst treating, following an appropriate exercise regime, and working on a large, thick mat.
Lifestyles - The majority of practitioners/students do some other work in addition to Shiatsu. This other work is most commonly sedentary in nature.
- The majority of practitioners/students engage in some form of sport or other activity thought to promote good health (eg. yoga).
- The majority of practitioners/students engage in some form of activity outside Shiatsu which they believe places demands on their hands. The most common such activity is typing / computer work.
It will be noted that I have used words and phrases like ‘may be’ and ‘appear’, rather than drawing any definite conclusions. The reason for this is that I have sought to be statistically rigorous in the way that the data has been interpreted. Clearly there are many different factors that may affect a person’s risk of injury. The more factors there are then the greater the size of the sample (ie. the number of respondents) needs to be in order to draw any truly meaningful conclusions. Hence, although much of the data is quite suggestive, a larger study would be needed to confirm some of those suggestions with a degree of statistical confidence.
Regardless of the nature of the specific injuries it is of great concern that at least 1 in 20 respondents believe they have been injured in some way by practising Shiatsu. I suggest that there are several possible reasons for this:
- Some practitioners/students are not practising certain aspects of Shiatsu correctly
- Some practitioners/students are not making use of supplementary exercise regimes or lifestyle choices to ensure that they can cope with the rigours of practising Shiatsu
- Some practitioners are simply working too hard, and not giving themselves sufficient opportunity to rest
- Some aspects of Shiatsu practice are inherently damaging to the giver, at least for some practitioners/students
Since my first involvement in Shiatsu I have understood it to be a holistic practice. However, I fear we may be addressing the needs of our clients whilst to some extent neglecting our own well-being. Should we suffer so that our clients can benefit? Of course not, but that is exactly what some of us appear to be doing. I believe we must give both giver and receiver equal attention in order to truly call what we do holistic. It is my intention in a future paper to examine the reasons that the above health problems occur and what we can do to help ourselves.
Footnotes: - http://health.groups.yahoo.com/group/shiatsu/
- For such a correlation to be termed ‘statistically significant’ we must be at least 95% certain that the correlation still holds when scaled up to the whole population.
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