RSI and Adverse Mechanical Tension Richard Donkin 12 Feb 93 Version 2.0 I've received a few requests for info on Repetitive Strain Injury (RSI), including adverse mechanical tension (AMT), so I thought I'd put this note together. My aim is to pull all the relevant info together, and gather comments, to make sure this file is a good general intro to RSI, AMT and how to treat yourself if you have it. I am not an expert on AMT (and nobody yet uses this acronym that I've heard). However, I can relay some info from a physiotherapist with 5 years experience of treating RSI, called Wendy Chalmers Mill. She has very definite views, which seem very plausible to me at any rate, but there is not very much consensus in RSI. She has worked for most of this time with one of the leading RSI specialists in the UK. Since a lot of information in this message was cribbed from a talk by Wendy, she asked me to include details on how to contact her - you can find these at the end of this message. Many other physiotherapists are aware of AMT, including the ones treating me; however, this explanation is the best that I have heard so far. The following may well contain errors introduced by me, especially where I have added material for clarity; I have also added some of my own opinions on how to manage your RSI yourself, which have been gleaned from a wide variety sources, including a local RSI support group. A word about how AMT fits in with other disorders. The overall syndrome is Repetitive Strain Injury (RSI), also sometimes referred to as Work- Related Upper Limb Disorder (WRULD) in the UK or as CTD (Cumulative Trauma Disorder) in the US. RSI includes several disorders, including the following: 1. CTS -- carpal tunnel syndrome, where nerves are compressed in the wrist's carpal tunnel, largely due to tendons expanding as a result of overuse. This is a very common diagnosis, especially in the US for some reason. 2. Tendinitis/Tenosynovitis, where the tendons or the tendon sheaths, respectively, become abraded due to overuse. Also a common diagnosis because physical signs can be detected. 3. Adverse mechanical tension, where nerves get shortened through static posture and stress. Quite often, more than one disorder can be present in a single person with RSI - for example, CTS and AMT. AMT is often mis-diagnosed as CTS or tendinitis - at one point, my AMT felt just like CTS. Medically speaking, the term 'RSI' is controversial, since there is little understanding as yet of what it consists of; therefore, some doctors prefer to exclude CTS and tendinitis from the scope of RSI. NOTE I am not medically qualified, and everything in here should be checked with therapists who understand RSI and are aware of AMT. If they haven't heard of AMT, or deny it exists, consider a second opinion. ---------------- RSI (Repetitive Strain Injury) tends to progress through a number of stages, usually including pain, stiffness, tingling and/or numbness in the following areas - often in this sequence, though not always: 1. Neck/shoulder (often just stiffness) 2. Hand/wrist 3. Lower and upper arm As the condition advances, arms and hands may become weaker and other symptoms may appear. However, there is very little fixed pattern to RSI symptoms, so every case will tend to be different in detail. RSI is *not* a very good acronym. The main problems are not caused by Repetition, though this can 'kick you over the edge' into a flare-up. Nor is Injury itself always a big factor, though some people may indeed have tenosynovitis, nerve damage due to carpal tunnel syndrome (CTS), and so on. The three main factors in RSI, according to the AMT theory, are: 1. Poor, static posture This means you are sitting in the same position all day, with arms flexed (i.e. bent) for typing, writing, reading, or meeting people. Without enough breaks, and with a poor posture that increases the static loading on a number of muscles, the muscles then become shorter and denser, impeding blood circulation, especially in the arms, neck and shoulders. This is usually first signalled as back pain, shoulder pain or neck ache, as much as FOUR OR FIVE YEARS before hand pain is felt. Think back to whether you have ever had stiff shoulders or an aching neck, especially after a lot of fixed-posture work. This 'adverse mechanical tension' leads to nerves becoming 'tethered' within groups of locked-up muscles, usually in the shoulders and upper back. This is rather like a hosepipe getting snagged in pebbles/rocks on the ground [this may require translation for US English]. Eventually, 'neural tension' develops -- this is purely physical and has nothing to do with being tense psychologically. The nerves simply contract, usually those which are never extended (e.g. the ones running along the inside of the arms). In this state, raising the shoulders (common while driving) or using the arms in a bent position for some time will cause pain. This pain is REFERRED PAIN -- caused by nerve tension all along the arm, and by tethering in the upper back, but felt as pains in the fingers, hand, wrist, forearm or upper arm. This is very hard to believe until you find that neural stretches make what seemed to be a damaged part of your arm get better (see below). Electronic keyboard work is worse than mechanical typing partly because fewer breaks are taken and the posture is more rigid. Mechanical typewriting is worse than writing, for similar reasons. A quick exercise/test for nerve contraction: drop your arm straight down by your side, palm forward, elbow fully extended (locked), and then drop your shoulder (use your other hand to help if you do this a lot). Then bend your wrist back until you feel a slight 'pull' in your middle and index fingers -- this is the nerve being stretched back. If you are able to bend your wrist 90 degrees back in this position, that's good. Don't use your other arm except to push down the shoulder. There are many variations on this neural stretch, which are technically called 'brachial plexus' stretches. This stretch is active since it involves the arm's own muscles in the stretch; if you have RSI you may find passive stretches, in which you lean against a surface, are less demanding. Don't push any neural stretches too far, even if they don't really hurt -- just go a bit beyond what is easy, and do the stretches frequently, for 10 to 15 secs each time. 2. Stress Stress multiplies the problem of static posture manyfold, because the muscles automatically tighten up when you are stressed, making your posture even more immobile and further tethering nerves in the upper back. This is the source of the common misconception that RSI is psychological in origin (for example, British Telecom's Chief Medical Officer has stated that RSI is a non-existent disorder (sic), thereby implying that all sufferers are malingers). So: you feel tense, stressed, under imposed or self-imposed deadline/productivity pressure, harassed by software or hardware that breaks, hassled by problems at work or home, and all this simply makes your RSI worse. You go to your doctor, who notes your stressed state but often cannot find anything 'physically wrong' with you (i.e. no obvious arm/hand damage), leading to his/her feeling that it is psychological. Even more insidious: if one person in a group gets RSI, the others immediately take note of their own pains and worry much more (= more stress), causing any existing AMT problems to be magnified. This is probably one factor in the very rapid spread of RSI within workgroups, which has caused some to mis-diagnose it as 'mass hysteria'. 3. Repetitive motion This is in fact the smallest risk factor. However, it does eventually cause relatively minor injuries, in the same way you get tennis elbow from overplaying tennis. These injuries are greatly exacerbated by poor, static posture and by stress; they would often heal up but are prevented from doing so. They are localised and cause localised pain, unlike static posture and stress. It takes years to get to the point of shoulder, hand then arm pain and can therefore take a long time to cure (though the cure time seems to be a lot less than the time to get RSI, thankfully). The AMT theory agrees generally with the views of other types of therapist, such as Alexander teachers and cranial osteopaths. The following treatment by a physiotherapist (= physical therapist) skilled in AMT seems to be fairly standard: 1. Testing for 'adverse mechanical tension' -- this involves stretching the arms and turning the neck to see where contraction/stiffness prevents further motion. 2. Mobilising the cervical and thoracic spine (i.e. neck and upper back), which unblocks locked-up muscles and helps nerves to extend. Very little arm treatment initially, maybe 2 mins in a 30 min session. 3. Stretching nerves, etc to reduce adverse mechanical tension -- this is demonstrated for 2 mins or so, then practiced by you continually throughout the day, whenever pain/aches are felt, and perhaps also in the evening for tens of minutes at a time. You will probably find that the RSI gets worse for a short period after treatment, but this should be less than 2 days, and it should then be better. You may have trouble finding a competent AMT physiotherapist: they are thin on the ground in the NHS, and the only hints are to find a physio who treats a lot of RSI patients and uses this type of treatment. In the UK, private physiotherapists are able to specialise, unlike NHS ones; also, Australian physios have brought a major base of AMT treatment skills into the country. Another possibility is to get trigger point therapy, also known as myotherapy. Trigger points are irritable parts of muscle that cause muscle spasm and pain; the therapy is to press hard on the trigger points, reducing the pain elsewhere, then massage and stretch the relevant muscle. This has helped a number of RSI sufferers; it is complementary to AMT physiotherapy, since it addresses muscles rather than nerves. I suspect that there is some overlap with AMT-style physiotherapy, since the approach used in mobilising the spine is not that different to trigger point therapy. Some physiotherapists do trigger point therapy as an additional technique (some inject the points, which does NOT appear to be a great technique); also, non-physios do trigger point therapy, in particular Certified Bonnie Prudden Myotherapists (CBPMs), who operate largely in the US and have stringent certification standards. I have had good results from myotherapy; call Bonnie Prudden Inc on +1 (602) 529 3979 for details of therapists in the US, and for videos, massage tools, etc. One of the key points is that you can treat yourself whenever necessary, which vastly increases the number of treatment hours per week and should speed your recovery. Another alternative therapy is cranial osteopathy - better termed cranio- sacral osteopathy, the theory behind this is somewhat involved, but it concentrates on re-balancing the body's 'internal energy' by releasing the fascia, the thin connective tissue that covers muscle, nerve, etc. The fascia seem to become contracted in various places in the body, and cranial osteopathy helps to release them, enabling the body to physically re-adjust itself. One hypothesis is that, while typing, glucose is sent to those parts of the body that are moving *and* to those that are held static. The glucose in the static parts (e.g. wrist and shoulders) then breaks down into lactic acid rather than being metabolised into energy; lactic acid crystals then build up on the fascia, making it harder for the fascia to move against each other. I emphasise that the above is just a hypothesis, but it has elements in common with the AMT theory. Controversial advice from Wendy: don't get a diagnosis! The theory is that simply labelling yourself will not help you, the real issue is getting treated. I have to say I disagree with this; you need to see a rheumatologist who specialises in RSI (NOT an orthopaedic surgeon, they are understandably biased towards surgery) to check that you do not have some non-RSI disorder and to discover if you have advanced CTS, necessitating surgery. Having said that, if you get a diagnosis that presents no hope of recovery due to medicine's ignorance of RSI, that can be a mental barrier to successful self-treatment. Maybe you should get a diagnosis to make sure that you don't have CTS, and then ignore the diagnosis! There is a huge number of things that you can do to help cure yourself, which help both psychologically, in that they help you control the pain and the condition, and physically, by helping to reverse the effects of RSI. In addition, the time you can spend on self-treatment far exceeds what you could hope to obtain from doctors or therapists. Here is the list - despite its length it is not exhaustive: Avoiding or mitigating poor, static posture - almost any sport (but avoid swimming with breast stroke unless you use goggles and put your head underwater -- otherwise your shoulders will get worse) - frequent breaks, with stretching, walking around, chatting, standing up to make phone calls, etc. Various software tools exist to help you take breaks and exercise, contact me for a list. The Japanese approach of everyone doing exercises in unison may not be right for other cultures but it has a lot to recommend it. - mixing typing with phone calls, talking to colleagues, writing (but be careful with writing, see below). - all the normal advice on ergonomics -- particularly, try to drop (not push) your shoulders DOWN (probably need to raise your chair and maybe get a foot rest). Your knees should be almost touching the underside of the desk - that way your shoulders can drop while your forearms are parallel to the keyboard. Hands should drop down onto the keyboard, with wrists higher than the keyboard. There is lots of good existing advice here, so I won't repeat it. - Alexander technique: this aims to correct unconsciously poor postures at all times and has been found VERY effective for long-term recovery from RSI - Feldenkrais method: this tries to correct poor body movement habits through movement exercises - alternative keyboards that allow typing with palms facing left-right not downwards (reduces strain on forearms) - keep moving! Try to avoid just sitting in front of the TV or reading a book for long periods of time -- get up, take a walk, go dancing, anything that gets your upper back/shoulders moving without using your arms too much. The mental image of a monkey, continually moving about and fidgeting, is not a bad one! - when driving, try to shift arm position frequently, and keep your shoulders down. Adjust the steering wheel down as far as possible, and drive one-handed, switching hands. Also try cushions to raise you up a bit. - when writing, try to adopt a similar posture to when typing, i.e. do not lean forward and down as far as possible. Try using a lower seat or higher work surface. Inclined work surfaces cost very little in some cases and simply rest on the desk (will also help back pain). Be *very* careful of your posture in writing, try to keep your shoulder 'loose' and relaxed). Some people have found that RSI from typing sensitised them somehow so that writing then caused pain in different parts of the hand/arm. - massage of various types, including shiatsu. Various massage devices are available, including 1. Massage device from C&A, Oxford Street, London: 10 pounds, battery operated, can lean against it if your hands hurt too much. Find in the Gifts section. 2. Novasonic Popular Plus: about 130 pounds, mains operated, well built. This generates sound in audible range within body (not ultrasound, so quite safe for personal use), allegedly helping healing from various muscular problems. It also acts as a massage tool, and seems to be good for at least short term pain relief. Available from Novafon Ltd, Scotland, 0796 472735. Lots of testimonials for non- RSI conditions. A few people with RSI have found this good for short term relief. - self-administered trigger point therapy; a number of tools are available to help in this area, which I have found the most effective in managing pain from RSI. See the Bonnie Prudden book, and contact me if you want to get a UK supply source set up. The best bet is to combine a deep-seated change of posture, which will require training, with increased motion to keep your upper back mobile. Some more controversial advice from Wendy: - consider not using arm rests (whether on chair or designed for RSI sufferers): these risk pushing the shoulder up, and enforce a static posture, but may be OK otherwise. - consider not using wrist rests, for similar reasons. If you do, use a VERY well padded rest, and never the table, and never ever the edge of the table. The theory is that making the arms work a bit is a good thing; I find my wrist rest very helpful in reducing strain on the arms and ensuring my wrists are above the keyboard. Regular (every day, one or more times) stress reduction - deep breathing exercises (sit up, or lie down on floor with slim pillow, but not on bed) - meditation - do this anywhere, anytime, can have dramatic effects - yoga - listening to heart beat - tai chi, qi gong, other 'soft' martial arts - these also seem very good at re-educating the body and its 'energy flow'. - biofeedback - flotation tanks - very good for deep relaxation - massage of various types, including shiatsu Quote from Wendy: 'you should become an expert on relaxation'. Relaxation is the best way to relieve pain - if you are practiced at meditation, you can turn off pain quite quickly wherever you are when it hits. Avoiding repetitive motion - slowing down your typing - try a Dvorak or other alternative keyboard More controversial advice: - only use heat, cold, ultrasound or laser treatment as a temporary palliative, and use relaxation for pain control in preference. The former techniques will not cure you and are less applicable at every point in the day - e.g. at work, on a train. All types of pain control are temporary palliatives, however. - consider not getting CTS surgery: AMT treatment can help people who are mis-diagnosed as having CTS, and *possibly* even some who have genuinely got CTS, though you have to think VERY carefully about this, since if CTS is advanced you have only a limited time to get surgery before nerve and ultimately nerve sheath die-back occurs, which is not reversible. Here you really need expert advice from someone who can advise of the relative merits of each form of treatment, in an unbiased way. Getting more sleep can be important if you are already not sleeping enough; however, circulation slows and fluid retention increases during sleep, which can make the RSI (and particularly CTS) worse when you wake up. Generally, sleep helps because you are not stressed or in a static posture, but meditation etc gives much deeper relaxation. Complete rest from ALL hand/arm activity (i.e. sitting in bed all day) is NOT recommended: this simply makes the static posture problem worse. If your arms are painful, try walking with your arms swinging gently. RSI is usually completely reversible providing you don't let it get too far: e.g. very severe pain at all times may not be completely reversible, though it can probably be helped. Basically, even if you are in a bad way, something can probably be done, so don't despair! If you have shoulder or neck pain, you are at some risk -- the next stage is likely to be hand pain unless you apply the above. If you have pain in your hands or arms, YOU MUST GET TREATMENT ASAP or resign yourself to progressively worse bouts of RSI. The pain normally goes away for a few days, weeks or even months, depending on the above factors, but this does NOT mean you are cured - it will be worse next time unless treated. The treatment will probably be physiotherapy, with exercises to do during and outside work - it won't mean time off work. If your hand/arm pain persists outside work and does not settle overnight, your condition is further advanced, but the advice is as above. You need to take time off from typing or whatever activities cause you pain, NO MATTER WHAT. Do not delay this, you are simply making matters worse -- the sooner you take time off these activities, the less time you need off and the quicker you recover. You may be able to continue doing some typing, but the rule is -- IF IT HURTS TO DO, STOP IT COMPLETELY. If you want more info, contact me or get one of the books below. Other other sources of info would be interesting to hear about: I believe significant work on AMT was done by David Butler, an Australian researcher. Here are some references to books, with my comments where I know something about them. This is only a partial list, additions with comments are welcome. RSI --- Repetitive Strain Injury: The Keyboard Disease, Edward Huskisson (Charterhouse, tel +44 71 606 2435) This is written by a doctor, who is somewhat doubtful of the value of ergonomists, physiotherapists and anecdotal experience. He disagrees with the AMT theory in detail but has a fairly similar viewpoint on the combination of physical and psychological factors in the development of RSI. Overall, it is good at describing the disorder, including history, symptoms, ergonomics, legal aspects, but has very little on treatment. Seems to believe that physiotherapy is of little use, which is not the case for many people. Also believes that surgery, drugs, injections and seeking compensation are harmful to recovery. Useful book, however, since it is the only one I know of that focuses on RSI. Trigger point therapy / Myotherapy ---------------------------------- Pain Erasure - The Bonnie Prudden Way, by Bonnie Prudden (Ballantine Books, New York, 1982), ISBN 0-345-33102-8 (paperback) This book shows how you can treat yourself and others using myotherapy, with specific guides to treating hand, arm and other pain, using pressure on specified trigger points, followed by stretching exercises. Gives some dramatic examples of speed of cure for other disorders; these should not be taken as indications of the speed of recovery from RSI, but trigger point therapy is very helpful for the few RSI sufferers I know who have tried it. Myotherapy - Bonnie Prudden's Complete Guide to Pain-Free Living The Dial Press, Doubleday & Company, Inc., Garden City, New York, 1984 IBSN 0-385-27755-5 This is a more detailed coverage of similar material. The Pain Erasure book is the best one to start with. Relaxation ---------- Full Catastrophe Living (New York, Dell Publ), ISBN 0-385-30312-2 Gives details of a type of meditation that is (for me) easy to get into compared with some others, though it still takes some effort. Contacting the author --------------------- Please let me know your comments on this note, including other therapies, success or otherwise with these therapies, and useful treatment resources, so that this note can be updated. Richard Donkin Work: richardd@hoskyns.co.uk Home (CIX): richardd@cix.compulink.co.uk (PREFERRED) Tel: +44 71 704 6775 (home) Contacting Wendy Chalmers Mill ------------------------------ Wendy now has a business that provides a complete RSI prevention service to companies and other organisations. She will also provide advice for people within these companies who already have RSI, and does diagnostic sessions for individuals. Her business is called Interact, is based in London and is on +44 81 968 6633.