” … by IrishJobs.ie,  Enable Ireland and Assistive Technology Training specialists asked more than 1,000 employees about how comfortable they were as they work.”

OK, this was a smallish survey of 1000 employed individuals in Ireland, but perhaps it provides  a glimpse into how widespread Repetitive Strain Injuries actually are in the workplace. The findings showed that -

“… workers now typically spend from two to more than six hours seated at work, typing at the computer or on the phone. Of the 45pc who have experienced RSI symptoms, the back was the most affected area, followed by the neck, wrist and hand. Arms and shoulders were also seen as problem areas. More than half of survey respondents said they only suffered from mild discomfort, but 44pc said it was painful enough for them to be aware of it. Four per cent described their RSI symptoms as “extremely painful.” “

I have suspected for a long time that a larger percentage of workers than officially register an RSI do actually suffer from mild forms of RSI quite frequently. They are, however, perhaps just trying to deal with the symptoms themselves and are reluctant to appear like they are complaining to their employers about anything that may impact their job security or the perception of their ability to work.

Note: Despite searching for the actual survey results from  Enable Ireland, I can’t find an original source for it. If anyone has a link, please drop me a comment.

I did however come across this very useful looking document titled “A Tool For Everyone” about RSI for employers and managers on Enable Ireland website, which does reference a 45 percent figure, just not the survey I was looking for!

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As it turns out, the movie was indeed quite prescient. Already we are seeing the trend towards computer tablets and anyone who has marvelled as they swished their fingers around an iPad screen, for example, will question whether they would ever willingly choose to use a mouse again. Not only that, Apple have now introduced some (by most accounts) rather impressive voice recognition software, namely Siri. Microsoft can’t be left out of the future, and the promise that their Kinect technology holds, if their slick ads are anything to go by, takes it well beyond the realms of Xbox games. Indeed, it has just been announced that Kinect is continuing its move towards Windows compatibility (next year) with the release of a SDK (software development kit) which will allow developers to create applications and games enabling the use of the Kinect add-on in Windows 8. After Kinect for Windows is released in 2012, in the words of Microsoft, “… the potential goes exponential”.

So I am feeling encouraged that the days of punishing input devices are numbered and that users will soon be able to interact entirely through natural body movement and voice. I picture the day when we see a mouse on display at the museum and chortle at how primitive a tool it was.

The future is arriving and it’s looking bright!

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“Worries about job losses have helped stress become the most common cause of long-term sick leave in Britain, according to a report that underlines the pressures on workers in a deteriorating labour market.

Stress has overtaken other reasons for long-term absence such as repetitive strain injury and medical conditions such as cancer.”

The article continues:

“The report highlights the strong links between job security and stress levels, with employers that are planning redundancies most likely to see a rise in mental health problems among staff.”

This is certainly to be expected given the current challenging economic times that we live in. I think the main disconnect in these articles about stress is that they infer that stress is a condition on its own, when stress in actual fact can lead to people being more susceptible to injuries and illnesses including Repetitive Strain Injuries (RSI) and many other health related conditions and, as such, we may not really have seen the full impact of stress on the British workforce.

Indeed I said as much in my article (from Dec. 2008) about it in the last major economic downturn in 2008 titled “RSI potential in these stressful economic times“.

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The main reason that I have been able to do kayaking is that my repetitive injuries in the arms have been localised in the forearms, wrists and hands. Kayaking is is an activity that is mainly done using the upper arms, shoulders and body for rotation and, as such, is not an activity that aggravates computer related RSI in the forearms.  I do, however, have to be careful with my bad right hand wrist. I have also had to use a neutral bent crankshaft paddle to keep the wrists from flexing, which does create pain with a more straight shafted paddle.

What I have recently been experiencing is pain around the elbows, that becomes apparent when kayaking, but goes away when I stop paddling for the day. Having been acutely aware of repetitive injuries, and also having read some good resources, I have at least identified what I believe is causing my elbow pain, I just haven’t yet figured out how to stop it from occurring in the first place!

A very useful resource for sore and tight muscle tissue and referred pain is “The Trigger Point Therapy Workbook” by Claire Davies a book which I have referenced in previous posts. From doing an analysis of the pain in my outside elbow, I was able to see that  a common referrer for such pain is the triceps muscle group. According to the book (ref pg 101-103, ‘Triceps’) there are trigger points in 5 separate  areas of the triceps than can refer pain into the outer elbow. Probing the triceps with my thumb identified an extremely sore and tight inner triceps muscle (referred to in the book as number 1 trigger point), about 4 inches down from the armpit. There were also very tight and sore muscles at the lower end of the triceps right where it meets the elbow (referred to in the book as triceps trigger point areas 2, 4 and  5). I had no tightness in the outer triceps (called triceps trigger area 3).

The tricep/elbow pain issue has come about as a result of a few windy, ‘slog’ like paddles where I am perhaps gripping the paddle tighter than normal, whilst pushing against the wind, coupled with perhaps a non optimal paddling technique. I maybe need to work on more torso rotation on those windier days out, or perhaps switch to a more straight arm paddling style. I may also have to introduce  some warm up stretches before setting off to paddle.

The triceps are one of the harder muscle groups to stretch out, and one of the only ways seems to involve putting your arm right over your head whilst pushing against your elbow or holding a weight to stretch the triceps further, which involves rotating the shoulder joint  as far as possible, which isn’t ideal.

I have started some nightly massage as well as stretching of the triceps muscles and some weights exercises in the hope that I can get them to quickly settle down to a less tight state and obtain some pain free paddling as a result.

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Let me start off by saying that trigger point therapy has been a fantastic tool for finding muscle knots in my arms, relieving and deactivating those knots through massage, and generally helping me understand a large part of what is going on with my arms. In the process of the trigger point therapy, however, I experienced (and still have) some ulnar compression going on in the nerve of the right hand which manifests itself in numbness in the outside edge of the pinkie (I don’t know whether this is related to the therapy or not) and I have currently greatly reduced trigger point massage to focus on the ulnar issue.

Does this put me off trigger point therapy? No! On the contrary it is one of the best methods I have encountered in understanding my RSI condition (and other painful soft tissue conditions), and potentially fixing it long term.

I am a 15 year sufferer so my condition is most likely a bad case, but what I have found with trigger point therapy is that you can deactivate a lot of the larger trigger points (muscle knots). I have also noticed that I still have many sites of smaller, much deeper tissue that still generate a lot of referred pain. As these are deeper down in the forearm, they are harder to access, massage and deactivate. I am also amazed at how many trigger points that I have found in many areas of the forearms. It is apparent that computer use, repetitive injury and continual adjustments to try to ease the pain when using a computer can lead to muscle knots forming in all kinds of places in the forearm. It’s not much wonder that such conditions are hard to diagnose, treat and recover from.

So in summary, I have currently backed off from trigger point massage due to the ulnar nerve numbness, but I am still 100% bought into this therapy for helping RSI.

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Trigger point therapy, as discussed previously in my post “Does forearm extensor trigger point massage offer a potential cure for RSI?”, is a method of massaging trigger points (muscle knots) that refer their pain elsewhere eg forearm extensors into hands and fingers.

Before starting Trigger Point Massage it is essential to understand the anatomy of the forearm muscles and what they do, where they form muscle knots and where they refer pain to, and as discussed in a previous post, the Trigger Point Therapy Workbook is a great place to start with this understanding.

Weeks 1/2

The first two weeks were mainly spent in a lot of pain, easily finding extremely sore trigger point muscles of the forearm extensor groups. I had exceptionally sore areas in the Extensor Carpal Radialis Longus, Extensor Carpal Radialus Brevis and the Extensor Digitorum. Couldn’t find anything going on in the Extensor Indicis despite having had a history of index finger overuse and pain previously.

Massage was done mainly by supported thumb, and knuckles, 3-4 times a day. Excruciating pain was experienced during massage from many of these trigger point areas, and as such can lead to a reluctance to continue, however I just had to keep saying to myself  “this muscle is sore and it shouldn’t be”, grit my teeth and keep massaging!

Most of this period was spent in continual pain from the massage. It is a recurring theme with trigger point massage. Your arms spend a large portion of time in pain from the massage as well as the RSI condition. So there is very little opportunity to asses any progress. I reckoned, however, that if I am massaging sore tissue then that must be a good thing!

Weeks 3/4

As the sore extensor muscles recovered from their intensive massaging of the previous weeks, the forearm felt less painful, but it was a gradual process. Sometimes taking a day or two off of massage treatments helps, just to give the arms time to recover and to allow you to assess progress. I had massaged out the eye-wateringly sore extensors, but there was some deeper down trigger points in lower muscle  tissues to try to access, as well as a persistent ache at the point where the extensors attach to the elbow. I also found a sore trigger point in my Extensor Carpi Ulnaris, which I subsequently found massaging can lead to a nerve type pain down the outer edge of the hand wrist and  little finger, which wasn’t good, and is something to be wary of. If you are trying trigger point therapy yourself, please be careful not to massage nerves!

I have used my thumb for massaging, but as stated in the Trigger Point Therapy Workbook, extended use of heavy pressure with the thumbs alone can lead to sore thumbs pretty quickly and as such is not advised.  The book recommends the use of balls eg tennis balls (or denser rubber ones) to roll your arm muscles against beside a wall. They also recommend a ‘Knobble’ which is a hardish object that you can grip with a knobbly protrusion which can be used as a pressure point for massage. I have generally just used my hands (knuckles and supported thumb) and a beach pebble (with smooth rounded edges) for massage through a fleece top, and both have worked quite well, although its very tempting to resort to using the thumbs which really should be avoided!

Weeks 5/6

After massaging out most of the extensor trigger point (muscle knots), I still have sensitive tissue areas around the elbow where the extensors attach, and this area is still being worked on. After a suggestion from James of How I Overcame RSI I also checked the inner forearm muscle called the Brachioradialis which is a muscle on the inner side of the arm that attaches to the lower end of the upper arm, and is used to bend the elbow. Under this is a smaller muscle called the Supinator which turns the hand palm side up. Much to my surprise, I found trigger points in both of these especially at the points close to the elbow/lower upper arm. The book suggests that trigger points here can refer pain to the thumb area as well as the inner forearm, but James also indicated that in his experience they also referred pain to much of the forearm too. I also found a small trigger point on the Brachialis (bicep) of the right arm, and have massaged it too. The Trigger Point Therapy book says that this point can refer pain to the thumb.

Progress

Progress is actually a difficult thing to asses on an ongoing basis. As I have mentioned before this is because you are in quite a lot of  pain from the massage for a large part of trigger point therapy. You literally spend a lot of time massaging, and even after the sorest muscles are less sore, there are still a lot of aches around and you are still stressing the forearm muscles with massage. The only real way to assess progress is to take a two/three day halt in proceedings, and see how they are. I’ve done this a couple of times, and yes the arm muscle pain of RSI does seem to be improving, it’s just not gone yet!

I am, however, very encouraged by the less screamingly sore muscles in my forearms, and am tending to focus on secondary areas now. I still feel pain from typing and mouse use, but much less intense than before, which must be a good thing. How sore the pain would be after a more demanding day of computer use is another question altogether though!

There are also other potential areas according to the Trigger Point Workbook that can refer pain to the arms and hands, including the Scalenes (shoulder neck area) and Triceps (back of upper arms), so more investigation of these areas for trigger points is required. I also am doing a lot of deep probing of the forearm extensors and finding a lot of  trigger points down there, which are very hard to reach and even harder to massage on a continual basis. Some of these small painful muscle fibres appear to be narrower than a fingers width and as soon as you get a finger on them to do massage they disappear to the left or right of your massaging finger before you get the opportunity to truly massage them, very frustrating!

I should also add in that I am doing some wrist rotations to work the extensor muscles in a fluid motion using a weight of about 1kg, and am also doing some work with a Powerball in slow motion.

I will continue to update on my progress here as therapy progresses, although I am at this stage very encouraged by Trigger Point Therapy as a potential solution!

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** Post updated with additional material at end on 16 May 2011 **

Trigger Points and RSI

I’m delighted to be given space to say a few things about RSI and trigger points. I battled with RSI for several years before finally overcoming it several months ago and I now have a very small website that details my journey back to full health. What helped me was discovering that trigger points (a.k.a. muscle knots) can be a significant cause for repetitive strain injury. Alan has already posted on the essentials of what I found in an earlier post titled “Does forearm extensor trigger point massage offer a potential cure for RSI?” He talks about an excellent book by Clair Davies and how trigger points can cause referred pain elsewhere. I will try not to be repetitive and just highlight a few points that I would make in addition to Alan’s post.

Trigger Points Refer Pain Elsewhere

What this means is that the pain you feel is not necessarily at the site of the actual problem. Normally, injured tissue is painful at the site where the damage occurs — if I cut myself with a knife, the pain is located at the very site where the skin is pierced. However, with trigger points, we feel pain in places where there is no problem at all. What seems to happen is that the brain gets confused about where the pain stimulus is coming from and we end up feeling pain some distance away from the real source of the problem. In other words, the trigger point (or muscle knots) refers pain to another location. The site of the trigger point itself is often not particularly painful.

This is very important to realise because the danger is that you will end up pointlessly rubbing away or massaging muscles to no avail. For example, I had searing pain along the outside of my forearm (i.e. the upper side) but this was actually caused by a trigger point on the inside forearm (i.e. palm side or inside forearm) near the crease of the elbow. If I massaged the top of my forearm where it hurt, it did nothing to resolve the problem. Not until I started to massage the underside (palm side) of my forearm at a specific spot near the crease of the elbow did the forearm pain go away. If you have the book by Clair Davies, this is described on p116 with the accompanying diagram figure 6.9.

I mention this because I recently had a conversation with a work colleague about trigger points and RSI. He was getting pain in his arms. He was very interested in my success with massage. Unfortunately, I forgot to explain to him about referred pain and he thought you had to simply massage the spots where you feel pain. Thankfully, I later managed to explain to him how trigger points refer pain elsewhere and he’s now purchased a book which is hopefully setting him right.

Another example is that I had a very sharp pain in the front of my right shoulder. I used to rub away at this place because it was so painful. Unbeknownst to me, there was nothing wrong with my shoulder. The real pain came from a trigger point in the infraspinatus which is a muscle round the back over the shoulder blade. Only by treating a trigger point some distance away from the pain did this help. In Davies’ book, this is on pp90-91.

Trigger Points Weaken Muscles

If you have been suffering from trigger points for a long time, the affected muscles can weaken. In the words of my physiotherapist, they “shorten”. So, getting rid of a trigger point (by deep massage) may not be enough. You may also have to rebuild weakened or shortened muscles with targeted exercises. Having suffered from RSI in my forearm for several years, my muscles had become quite weak. I found it difficult to hold an umbrella or a mobile telephone to my ear. Even after the trigger point had been “deactivated” (to use the proper term), I still needed to rebuild strength in my shortened muscles. My physiotherapist told me to use very small weights of 1 kg max and gently hold them in the way I might hold a microphone. I would then gradually rotate my hand and bend my wrists to slowly rebuild the muscles. It’s important not to use weights that are too heavy because the point about computer usage (and other RSI-inducing activities) is that they are “low load” work. You need to rehabilitate the muscle’s ability to cope with low load endurance. By the way, my physiotherapist said that a tin of baked beans serves as a very good alternative to a hand weight! Another alternative is a Powerball which if you spin SLOWLY, can achieve the same effect. I actually used the Powerball more than small weights but I tend not to recommend it so much because there is a danger that users will spin it too quickly and therefore not achieve the “low load” effect.

Massage Immediately after a Session on the Computer

I found it was quite useful to do massage after working on the computer for a short time (say 5 mins). In other words, I deliberately waited until the RSI symptoms had arrived before doing the massage. Typically, I would spend about 5 min on a computer whereupon my arms and shoulder would start to hurt a lot. I would then do the massage because it’s easier to find where the trigger point is when my muscles were raging with pain!

Other Good Books

I recommend The Trigger Point Therapy Workbook by Clair Davies but there are other very good books too. I really like Simeon Niel-Asher’s Concise Book of Trigger Points which has very good colour drawings but I found that it doesn’t contain quite as much detailed information as Davis’ work. Also, some of the trigger points I suffer from are not mentioned, although to be fair, it is a “concise” book. There is also a useful book by Donna and Steven Finando called Trigger Point Therapy for Myofascial Pain. It is not especially well presented but has some useful information that can serve as a supplementary details. It’s not as good as Davies or Niel-Asher but it is certainly an interesting resource.

Okay, well that’s all I would add to the previous post. You can find out more on my website  How I Overcame RSI.  Don’t hesitate to e-mail james@howiovercamersi.co.uk if you have any questions.

James J

Additional Information  16/05/11 (from James J)

One thing I would note is that I don’t think the book by Davies’ covers all of the possible trigger points ( and nor do the books by Niel-Asher or Finando). I am convinced that I found some other trigger points causing pain along the topside (outer side) of my forearm; these points are not mentioned in those books so I may be wrong but I am personally 100% convinced that I had trigger points at those spots. Until I started massaging those spots, I didn’t get much better.

Have a look at the image on the right. you will see that all of additional spots that I found are on the inside part of the forearm. Whenever I pressed them, they would have the characteristic pain of a trigger point i.e. they were exquisitely painful. Quite often, they referred pain elsewhere, although not necessarily to the outside of the forearm. You might want to give it a go. One of the spots, to be fair, is mentioned on page 116 of the book by Davies. It is figure 6.9 for the Brachioradialis. However, the pain pattern shows that only part of the outside forearm is shaded. I think that more of the forearm should be shaded – at least that was my experience. Of particular importance were the parts in the middle region of my inner forearm – see the four red dots placed together.

James J

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Trigger point Therapy Workbook

Occasionally you come across something that just makes sense, and after receiving an email from James, a fellow RSI sufferer, with a link to his website ‘How I Overcame RSI‘, I had a whole new set of data to analyse and compare. The thing that was interesting was that James as well as having a shoulder RSI to deal with, also had a similar condition to mine with overused forearm extensor muscles.

I have long been aware of the fact that I have overused forearm extensor muscles, and have documented this extensively on this site. What I haven’t been able to understand over the years was how to get these muscles to perform as muscles again or, indeed, if they ever would.  I have frequently used short term massage techniques with the extensor muscles to get very temporary relief  from bad forearm pain, but the benefits from this massage have never lasted beyond a day or so.

I guess my understanding of  forearm muscles has not been what it should be. This lack of awareness was not helped by a previous consultation with a ‘RSI‘ doctor (10 years ago in US) who told me that he didn’t know whether  my arm muscles would ever act as normal muscles again, hence I have been very pessimistic about ever finding  a cure. Massage from physiotherapists (including deep tissue massage) has also only been of limited success, although admittedly amounted to perhaps only a handful of 15 minute sessions.

So it is with this background that I read James’ website article, which gives a very detailed account of what he found out on his journey of RSI discovery. He has done a lot of the groundwork for us all, and for this we should be grateful. He has spent a lot of his own money on various treatments, and has clearly documented what worked and what didn’t work for him. What was enlightening was the fact that most of his learnings on RSI corroborated my thoughts on the subject too. So his insights immediately grabbed my attention.

What was most resonant with me was that James had managed to cure himself of a bad case of RSI simply by dedicated massage techniques and Powerball use alone. His techniques were based on ‘Trigger Point’  therapy, which, to cut a long story short, means that there are trigger points (muscle knots) in your forearm  tissue which create referred pain elsewhere, for example, in your hands. These trigger points can each be identified and massaged out using dedicated (up to 6 times daily) and sustained massage over a period of 1 to 2 months. The massage is best self administered since the chances of being able to see a physiotherapist 6 times a day for  two months would, I suspect, be zero! Keep in mind that you are also the person best suited to knowing where in your forearm actually hurts!

He recommended reading ‘The Trigger Point Therapy Workbook’ by Clair Davies, which provides self help for trigger point massage. I have purchased a copy of this book, and I too will pass on a big recommendation for anyone suffering from RSI. It really should be mandatory reading by every RSI sufferer, as well as every doctor and physiotherapist. It is one of the best books I have come across that describes RSI trigger points, along with individual muscle diagrams and very readable descriptions of the muscle functions. It also includes descriptions and diagrams of where those trigger points are located and where to expect referred pain. Basically, you look up where you have pain, and it tells you why and what to do. Although the book covers the forearms and hands, it is not limited in scope ie it covers the entire body, and may be of much use to anyone with any other aches and pains!

In my case it is the first time I have been able to identify individual forearm muscles their function, and the stresses that are placed on those muscles when using a computer. I have now started with (1 week) of self treated trigger point therapy (massage) and will report back here with regular updates. I have identified a lot of very very sore to massage trigger points in both my forearms!

Its difficult to assess effectiveness in the first week, as most of the week is spent literally in eye watering pain massaging the very painful knots in the muscles, and the tense ache of after massage muscles which naturally occurs. However after 7 days of this therapy some of the excruciatingly sore knots are less painful now when I rub them, so I have a lot of hope!

Will keep you all posted on my progress.

Many thanks to James for doing all the research, as well as sharing his findings.

Its the first time in ages I’ve felt slightly positive about my RSI condition.

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Up until I injured it, I didn’t even know that there was anything there to injure. I had been working out in the garden carrying stones in a bucket (a large muscle activity involving upper arms, shoulders, core, back) on and off for a day, when I finally sat down and noticed a general ache around the sternum area, as well as everywhere else I should hasten to add! Over the course of the next few days, all the aches disappeared except the one in the sternum. It was at that stage that I realised I’d injured something, I just didn’t know how bad it would be. Symptoms can include pain, tingling and an itching sensation around the centre of the chest area.

Over the course of the following week, I resumed my normal life doing picture framing, but noticed that I could induce bad pain in the sternum area when attempting to push against something heavy. This wasn’t good! At this point I did a little research and found out about costochondritis.  It is an injury to the soft connective tissue between the ribs and the sternum and can take a long time to heal due to the fact that there is not a huge supply of blood circulating to this area. I also got the advice of my GP who said that I just needed to rest it.

For the next 3 months I did my best to rest the chest area, which meant no lifting, pushing or carrying of anything remotely heavy in weight (including shopping bags!). One main difficulty I found was trying to rest the sternum while sleeping. The natural position of the body when sleeping on your side is to have both arms on the bed. This posture forces the sternum to be compressed and as a result does not give the area ample rest during sleep. Having restless nights also doesn’t help matters in this regard. One solution that I found is to sleep whilst hugging a pillow. The pillow has to be a puffed out largish one to keep the chest area open. It has proven to be a very useful method.

After 3 months of resting, the sternum had improved to the extent that I could actually do more. The question was, how much more? This, I found out by trial and error. If I did too much, the sternum would get more prickly, “itchy” and sore. It followed the same pattern every time: perform an activity, followed by prickly, itchy soreness for a few days, then it would calm down and I’d feel better again after a week. The trouble was that this went on for the best part of a year! Even now – some 14 months after the initial injury, I still have to be choosy about whether to try lifting something heavy or not. All in all, this injury has taken a long time to get better, and is one I could most certainly have done without!

The following are a few recommendations I would make for anyone suffering from costochondritis -

• Rest up well for 2-3 months, avoiding all lifting of things including heavy shopping bags.
• Hug a pillow while sleeping on your side to keep sternum area from being compressed.
• Gentle reintroduction to exercise – yoga can be a good form of exercise to start recovery, so too is swimming.
• You can use NSAIDs, eg ibuprofen to help with symptoms, but consult your GP first. I have also found much relief by taking Devil’s Claw (a natural anti inflammatory)
• Have patience and don’t rush your recovery. After 14 months I feel like I am back to 90%, but I’ve been in the 70-80% range for a long time (nearly a year) and have frequently found a way to aggravate it somehow, usually by carrying something heavy.  This has happened even up to the 13 month mark!

This condition has certainly been very persistent, and has been quite frustrating to deal with mentally as well as physically, but after 14 months I am finally feeling like I am getting there. Fingers crossed!

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