Massage Tools: What do we do with them?

Contributions by:
Rick Goggins,  Richard Gold,  Robert Granter, Joe Muscolino,  Greg Polins, Thomas Zudrell
An Irish bodyworker once said that Aussie therapists are very fond of tools. Not sure how true it is, but certainly some therapists like to use tools in massage and bodywork. Tools can help and enhance the therapeutic effects of a treatment, and tools can also help therapists preventing them from fatigue and injury. The highest risk for a massage therapist is mainly wrist, fingers, and thumbs injuries. A survey conducted by Terra Rosa a few of years ago indicated that 60% of the surveyed massage therapists in Australia have a prevalent to wrist and thumb injuries. According to Greg Polins, the inventor of Thumbsavers, the thumb is the most commonly (mis-)used body parts in massage. While Deep Tissue Massage and trigger points therapy can attract new clients and help a business grow, overuse of the thumb joint can have a catastrophic outcome. “If you are performing six to eight deep tissue sessions a day, five to six days a week, your hands are going to hurt. It’s simple physics. You can lower or raise your table, but at that eighth hour of deep-tissue work on your sixth day, your hands just hurt. When pain begins to interfere with work, a therapist might incorporate hand stretching, exercises, and yoga into his/her daily routine hoping to prevent further injury and increase strength. If this is not working, at the next step the therapist will decrease a stressful modality and start doing craniosacral therapy or energy work. Should these strategies fail to resolve pain issues, rather than looking for a new, less painful job, a therapist might want to consider using one or more tools.”
Thomas Zudrell, the inventor of Spynamics, sayid, “Tools in massage and bodywork can make work easier for the therapist, often faster, and sometime even more effective. The use of tools can leave a professional impression on the client as they encounter this all the time in conventional medicine”. According to Richard Gold “Tools can help preserve the practitioner’s body by lessening stress and strain, it provides an additional ‘set of hands’.”
Therapists usually resort to tools that enabled them to apply pressure without pain. Massage tools come in different shape and form. Broadly speaking, there are hand tools, tools that can be used to help to decompress certain part of the joint or muscles, tools that apply heat or cold, vacuum cupping, and tools that send out vibration, radiation. And here are just some of them.
Hand Tools
A variety of hand tools have been developed to help massage therapists, which include tools for trigger point work, muscle stripping, cross-fibre friction, or similar techniques that require deep, sustained or repetitive pressure.
Greg Polins, invented Thumbsavers from his daily experience as a massage therapist. In his eighth year of professional therapeutic massage, heI began to experience crippling pain in my thumbs and wrists from the extensive deep tissue massage. “My thumbs were so fatigued from a full day of massage that I was forced to ‘ice’ them every night. At one point the pain was so intense that it was difficult to hold a pen and write!!  My  thumbs looked like big toes.  Fellow therapists were either finding other modalities or abandoning their careers. Others would say ‘use your elbows more’…ever use your elbow for TMJ?  I needed a solution and fast I had too much time and energy invested in my training.” After considerable experimentation and countless prototypes, Greg developed an affordable massage tool that assists therapists by providing support and reducing the stress on your hands and wrists from deeper tissue massages, while protecting your most valuable commodity… your hands!
Because Thumbsavers is “worn” over the thumb, it provides a greater sense of dexterity for the user. Since it is smooth in texture, semi-flexible and latex-free, it feels natural for both the therapist and the receiving client. Its design helps the therapist to use ‘proper hand mechanics’ when performing massage, thus reducing the chance for fatigue, pain and injury. Greg added that “I felt such an immediate result from using it that I decided to bring it into production (sounds simple but isn’t) and share it with fellow therapists. All I needed was money to get started, so I sold everything that I owned except essential clothes and my massage table. I was starting from zero once again but I believed in my invention and my hands felt good again.
Since Thumbsavers massage tools were first introduced to the professional massage therapy industry in 2004 the response has been overwhelming. Awarded a Patent (7252645) its popularity has spread around the world in both professional massage therapy practices and massage therapy schools and institutions.  Greg said that he is deeply gratified knowing that Thumbsavers massage tools has helped so many therapists to continue with the careers that they have invested so much time, education selflessness.
Author and teacher, Joe  Muscolino, said that “I am not normally a lover of tools for performing massage because any contact other than the skin of our hand (or forearm/elbow) will not deliver the sensitivity needed for palpation assessment that is so important toward being an excellent therapist. However, there are times when tools can be very helpful; especially thumb braces for therapists who have hyperextendable interphalangeal (IP)  joints (and perhaps unstable metacarpophalangeal joints, MCP) in their thumbs. For these therapists, using a brace that supports the IP and MCP joints can make the difference between being able to successfully practice of not. I have not seen it, but it would be the best of both worlds if someone would come out with a thumb brace that supports the IP and MCP joints, but is open at the tip/pad of the thumb so that the therapist can still palpate and feel the response of the client’s tissues as the pressure is being exerted.”
There are also various tools that can be used for trigger point therapy including some ‘knobber’, and various forms of sticks. Tools with narrow tips (such as massage stick) can be used to get into tight spaces where fingers are too large (e.g. a massage stick can be used in reflexology).
A variety of hand tools is used in the TCM technique of Gua Sha, where a smooth edge tool is stroked with pressure repeatedly over lubricated skin. The tools can range from a ceramic Chinese soup spoon, a coin, a metal cap with a rounded edge, honed animal bones, or a jade. This technique is also used in Indonesia, known as ‘kerokan’ (meaning scraping), a form of Javanese folk therapy.
A modern implementation of this technique is called the Graston technique where a collection of six stainless steel tools of particular shape and size are used, dependent on the area of the body and the outcome required. These techniques assist in soft-tissue mobilization, to break down excessively immobile scar tissue and connective tissue restrictions. Graston technique uses a collection of six stainless steel tools of particular shape and size.  It is used to mechanically mobilize scar tissue, increasing its pliability and loosening it from surrounding healthy tissue. Graston technique was designed as an instrument assisted transverse friction massage popularised by James Cyriax, which was based on the theory of creating a traumatic hyperaemia and the prevention of adhesion formation.
Decompression and traction tools
There are also tools that help muscles and joints in particular region to relax, or provide traction:  such as sacral decompression, and subocciptal decompression
Spynamics Sacro Aligner was invented by Thomas Zudrell, with the intention to empower his clients with self-help and self-therapy to allow their body to do the necessary healing and adjustment reactions after therapy sessions. If these self-therapy exercises are done with enough self-discipline, clients often recover fast and have long lasting results. However this simple motivation has been a big challenge as clients often came back with various reasons explaining why they did not do their ‘homework’. So Thomas decided that he needed something that worked, safe to use, easy to understand, affordable and does not require too much time. This was the birth of the Spynamics Sacro Aligner. It started with an idea and developed into a great self-help tool that even achieved a Gold medal recognition in the world’s oldest fair for inventions iENA (International Trade Fair) in Nuremberg in 2008. The patented design follows the natural shape of the human sacrum and lumbar vertebrae and when used properly can help to regain improved lumbo-pelvic alignment, muscle relaxation and improved nerve function. It encourages and improves sacroiliac joint alignment by bringing the sacral base back into the ilia to decrease the strain on the sacroiliac ligaments. Using own body weight  while laying on the Spynamics Sacro Aligner together with simple dynamic movements, the structural system is guided into better alignment due to the natural mechanism of a myo-neuro-structural rebalancing.
A still-point inducer is a tool that helps to relax by resting your head on it. It induces ‘Still Point’ (a term given to the gradual stopping of the craniosacral rhythm, and is an indication that the body is making therapeutic changes). There is a commercial device available from the Upledger institute, or you can make it yourself from handballs. Take two soft handballs the size of tennis balls and a sock (tennis balls can be used, but it is quite hard and needs lots of padding). Place the two balls in the sock touching each other and tie the end of the sock. To use, lie on your back on a hard surface, place the balls at the base of your skull (in line with the bottom of your ears, as viewed from the side). Allow the weight of your head to rest on the balls, and relax for 10 minutes.
Heat or Cold therapy
According to Joe Muscolino, the use of heat therapy can be extremely beneficial to manual therapy. Joe believes that heat used in conjunction with soft tissue manipulation and stretching, as well as joint mobilization, allows for extremely effective clinical orthopedic work. Heat promotes general softening of myofascial tissues as well as relaxation of musculature, allowing the other therapies to that much more effective. Joe added that given how easy it is to buy a hydro collator (liquid heating) device and place a hydro collator pack on one area of the client’s body while working another, employing heat therapy should be a staple of all therapists who do orthopaedic/ remedial massage.
Cold therapy or cryotherapy usually involves the use of ice or ice packs. Ice is an anti-inflammatory that decreases swelling because it causes vasoconstriction of local arteries, and it is an analgesic that decreases pain because it can numb pain receptors in the region of application. We see cryotherapy is commonly used in a variety of sports: athletes with bags of ice on various parts of their body after a competition, or a more extreme version is jumping into an ice bath. By lessening the sensitivity, the client will likely allow deeper pressure to be used. Ice can also be used after deep tissue work to decrease swelling that might already have been present, or to prevent swelling from occurring that might result from the deep pressure. Cryotherapy can be applied using a commercial Cryocup, or using a home-made paper or Styrofoam cup. Fill a paper/foam cup with water but leave some room for water expansion and place it in a freezer. To use, peel off part of the paper to expose the ice, hold the cup and place and gently massage the ice on the required area.
There are mainly 3 types of tape: athletic tape, strapping tape,  and Kinesio Tape. Athletic tape is mainly used for acute injury treatment or injury prevention during sports activities. It is inelastic, therefore restricts some movement. It is applied before a sport activity and removed afterward. Strapping tape restricts some movement, and can help correct poor posture and limits painful movement. Strap tape has only an elasticity of 30%, and is useful for creating ‘bracing’ support to a specific part of the body. Meanwhile, Kinesio (or elastic therapeutic) tape or K tape has an elasticity up to 140% of its original length. It allows full movement and aids lymphatic flow. The tape is applied with the affected muscle in a stretched position, from the origin of the muscle to the insertion point.  There are some theoretical benefits, include correcting the alignment of weak muscles as well as facilitating joint motion as a result of the tape’s recoiling proterties. The tape also lift sthe skin, increasing the space below it, and increasing blood flow and circulation of lymphatic fluids. This increase in the interstitial space is said to lead to less pressure on the body’s nociceptors, which detect pain, and to stimulate mechanoreceptors, to improve overall joint proprioception.
Kinesio tape became very popular after being used by many athletes in the 2008 Beijing Summer Olympics and also in the recent London Olympics.
Vacuum cupping
In modern vacuum cupping, a vacuum pump is used to induce a vacuum inside a cylinder sealed to the skin. The vacuum “draws” the soft tissue perpendicular to the skin thus providing a tensile force to the soft tissue system, which can be left in one site for a prolonged period or moved along the tissue. Or it can be thought as a tool  for petrissage. Robert Granter believes that this modality is an essential tool for the Remedial Therapist as the benefits are clear for both client and therapist. Effective soft tissue mobilisation can be achieved &  stress can be taken off the practitioner’s fingers by its implementation.
‘The effects on the myofascial system and the nervous system are brilliant and the technique can significantly help to resolve many conditions” Rob continues “We often see indiscriminate and excessive use of Cupping and we therefore, encourage all practitioners wanting to learn Cupping to seek training with practitioners who have successfully integrated Cupping into their practices over many years”  Rob believes there is no need or justification for the excessive bruising often seen with this technique.
So how can you maximize the effectiveness of the treatment and limit adverse tissue reaction? Rob suggests 5 Vital Signs to adhere to:

  1. Watch and monitor the colour of the tissue being treated and do not allow the tissue to become a red/purple colour keep it to a pink colour. As soon as the colour changes to a red/purple remove the cup.
  2. Don’t leave the cups on for more than 2 minutes initially.
  1. Be aware of your patients skin type: Fair skin will bruise more easily than “olive” skin
  2. Monitor the degree of Vacuum inside the cup by watching the degree of Skin raise within the vacuum cup to ensure it is not excessive.
  3. As a guide only draw the skin approximately ¾ of the way up to the 1st treatment line on the cup
  4. Only apply the cup to sites where clear palpable broad myofascial dysfunction exists. If specific precision is required Cups are not your 1st choice

Here are some of the FAQ on using tools.
How can a tool help?
Using a tool can help a therapist to apply deep, consistent pressure with less strain on the hands and wrists. Tools also help by reducing the need to apply pressure through the fingertips, which can increase pressure in the carpal tunnel, potentially compressing the median nerve. “Pressure on the fingertips can also reduce blood flow to the nerves there, which could reduce sensitivity of touch. Tools are also a good substitute for using the thumbs. If you apply 4 kg (or 8 pounds) of force through the tip of your thumb, you can create up to 45 kg (100 pounds) of force at the Carpometacarpal joint. Do this often enough and you can damage the cartilage there.” Says Rick Goggins, co author of Save Your Hands.
When should we use tools? Are there times tools should not be used?
Tools may be used in a conservative context as a preparatory treatment or if direct hands-on work becomes stressful. Tools should only be used once a thorough assessment has been conducted including careful palpation to determine the exact target tissue.
Tools that have the capability to significantly impact on body structures may not be used before hand work.  Tools also should not be used when there are any contraindications for massage in general. Tools should also not be used around sites of potential endangerment, such as the anterior triangle at the neck and the femoral triangle.
Richard Gold warns that some clients might have trauma related to tools or devices. Client’s who bruise easily or are on medication that ‘thin’ the blood should be treated with additional caution.
What is a good tool?
“Simply put, a good tool fits the practitioner’s hand well, does not place pressure on the carpal tunnel at the base of the palm, allows a relaxed grip using the whole hand, and can be used with the wrist straight to minimize tension on tendons and reduce pressure in the carpal tunnel” Says Rick. The end of the tool also needs to feel good to the client, preferably in a way that is indistinguishable from the therapists fingers.
Thomas Zudrell suggests that  a good tool is made from quality materials, easy to use, durable and reliable. The application of a tool should be based on natural laws of anatomy, physiology and physics to assist or copy actual body mechanics. Vibrating tools should have a possibility to adjust the frequency of the vibrations, and Natural Materials should be the first choice
Should I tell my client when I’m using a tool.
“Yes, I think informed consent is important when using tools in massage. It may be best to let the client know at the beginning of the session that you will likely use a tool and make sure they’re comfortable with that. It may not be necessary to announce that you’re going to use a tool just before you apply it to a client. They may not even be able to tell the difference.” Says Rick.
What are the common mistakes in using tools for massage? 
Rick says a common mistake that can have serious consequences is using too much pressure. Because tools can require less practitioner effort, it can be easy to overdo the pressure when getting used to a tool. It helps to practice on someone and get a sense of the right amount of effort to produce the same pressure that you would with your hands. Client communication is also critical when using a tool on a particular client for the first time. Other mistakes come when choosing tools that are either too large or too small for the practitioner’s hand, or holding a tool with a grip that creates more strain on the hand and wrist than it relieves.
Richard Gold warns losing touch with our client’s by limiting direct touching contact and any hyper-extension needs to be avoided.
According to Joe Muscolino: “As a rule, braces and tools provide stability and often facilitate the therapist being able to generate greater pressure into the client than otherwise would have been possible. But these treatment tools should not obviate the importance of employing the best body mechanics possible; e.g., stacking joints and generating the force for the stroke from the core.”