” … 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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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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** 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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The idea is to have two waterproof (plastic storage boxes work fine) containers. Each one  should be just greater in length than the distance from your elbow to you finger tips. These should be filled with water to a depth enough to cover your arms when fully submerged.

One container should be ‘hot’ – not too hot.  ie. no greater than 40-45^oC (104-113^oF)

The other container should be ‘cold’ – cold tap water with a few ice cubes (or an ice cooler pack) in it to chill further to no lower than 10-15^oC (50-60^oF)

You will also need to have a clock or timer handy with seconds/minutes easily visible. A kitchen timer or stopwatch is good for this purpose.

The procedure is simple, and involves submerging your arms into the ‘hot’ bath for 1 minute, followed by submerging them for 1 minute in the ‘cold’ bath. Then repeat this switching between baths for 10 to 15 minutes (longer if desired).

You can repeat contrast baths a few times a day if necessary, but it may be impractical to do this at work. You could also increase the time from one minute in each bath to two minutes in each bath if found to be more effective.

This temperature cycling should help relax any stressed out muscles a bit, and give some immediate pain relief. At the peak of my RSI condition after coming home from work every night, I would do contrast baths to get some pain relief. Its a low cost and self administrable procedure that can help reduce RSI pain.

Please check with your health advisor first if you have diabetes, heart problems or Raynaud’s Syndrome before doing contrast baths so that they can determine whether it is advisable for you to proceed.

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Previously, while living in the US, I was sent for Bio Feedback monitoring, and was ‘hooked up’ to many electrode pads around my neck, shoulders, and arms. These were to be used to measure muscle tension in all the upper body limbs including the neck and shoulder area.  The sensors are connected to a computer which plots out the associated muscle tensions on a monitor, so you have real time visualisation of the various muscle tensions you hold in your upper body when operating computer equipment. You are actually seated in front of a real keyboard and mouse, and asked to type and enter data like you normally would in your daily life.

I was actually quite surprised at how much tension the signals showed, and was constantly told to relax the posture to drop the tension levels – not an easy task!

I had to really try to relax my whole body from my head to neck to shoulders to arms to wrist angle to make even the slightest difference. The difficulty was trying to hold it there whilst typing and using a mouse.

Emphasis was placed on relaxing muscles that control the upper limbs, as well as suggestions on how to become more relaxed in the mind both inside and outside of the office environment.

As with other RSI awareness education therapies, there was no magic bullet for me with Bio Feedback, but it certainly helped to raise my awareness of how tense my upper body limbs (including shoulders) became while operating computer equipment, and that really is an important part of the RSI education process.

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There are a lot of braces out there, and what works for one person may not work for everyone. Braces are usually made out of neoprene or elasticated material coupled with a metal or hard plastic support to immobilise the wrist.

The primary use of the wrist brace should not be forgotten ie to rest wrist joints and forearm muscles that drive the wrist motion (forearm extensors, flexors), and reduce the pain associated from overuse injuries. While this may sound like a good thing, quite often if you wear a brace while using a computer, you will end up using other muscles in a strenuous way to do the same work, and can cause other injuries because of this.

There is no such thing as an ideal wrist brace, it really depends on what they are trying to do.

In the course of your RSI journey you way well encounter many different styles of wrist braces.

My general rules concerning wrist braces are -

1. You shouldn’t jump in and buy a wrist brace without first seeking advice from a physiotherapist or doctor.
2. Ideally, it should be used to rest (heal) the wrist and the overused (painful) muscles that drive the wrist extension and flexion, and not worn when using a keyboard or mouse.
3. Exceptions to the rule are perhaps specific braces intended to stop excessive flexion of the wrist if you are prone to this. It’s a far better idea to be able to spot this flexion yourself and change it, but if you have difficulty doing this then a brace may be required. Alternatively have someone stand and watch over you with a big stick, you will learn faster then!
4. Braces used to rest the wrist should not be too tight, just a snug fit. Over tightening can lead to restricted blood flow to the hand and wrists.
5. Consider wearing a wrist brace at night in bed to avoid sleeping with your arms/wrists/hands in bent positions. It is critical that you don’t have a tight brace when doing this so as not to restrict blood flow.
6. Don’t use them unless you have to. Its better to know your pain, when it happens and try to make adjustments to your  work practice etc to reduce the causes than it is to just ‘bandage up’ your injured wrists into a brace.
7. Neoprene braces can be hot, sweaty, smelly and itchy to wear even for short periods of time. Better to look for ventilated elastic material ones.
8. Wrist braces are not a good  universal fit for everyone, so you may have to make some adjustments to it to make it comfortable, including cutting bits out of it or adding some customised padding.
9. Wear them at work and they do flag to your employer and colleagues that you have a RSI problem!

Remember though, wrist braces are not a solution to RSI, they are really only there to rest an injury and ease pain. To address your injury it is far better to try to make adjustments to your work to stop the motion that is causing you to have the pain. In other words, you should monitor your wrist, hand motions at a keyboard etc, and make adjustments to your bad working practices, including posture changes. You should also introduce more regular breaks away from your computer along with a good stretching routine and some physical activity.

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The RSI pain cycle once ‘locked’ into is a hard one to break free from. The common mistake is to address only one or two factors. If the sufferer is at an early stage of RSI, and is fortunate then one change eg ergonomic setup may be enough to break free, but any medium/long term sufferer who is trapped in this cycle should consider addressing most/all of the underlying trigger causes to allow the transition to an RSI free life. The second diagram (click image to enlarge) shows the key areas to address to break the cycle.

You can also download the 2 diagrams in Breaking The RSI Pain Cycle (pdf)

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It should also be noted that video gaming is a highly addictive pastime (I speak from the experience of my youth). Video games are designed to be addictive; let’s face it, if they were not, players would rapidly lose interest and move onto something else, and the manufacturers would not sell many games.

There are usually very high levels of repetitive motion involved to complete a game stage and there are usually many levels to  complete, which allow the individual to achieve the elevated status of finishing that level (quite often against the clock) and progress to the next with a sense of achievement. There is a high degree of addiction involved in this process which can involve spending literally many hours in a sedentary position whilst making very repetitive motions with your arms, hands and possibly feet while using keyboards, mice, joysticks and other types of controllers.

In the specific case described in the article, a girl came down with a bad skin condition involving sore lumps in her hands and feet after playing for hours on a gaming machine. In a quote from the article that refers to a Swiss doctors’ report it states that,

“Excessive video gaming is currently regarded as an alarming health issue… Recently, organic pathologies such as acute tendinitis, called Wiiitis, or video game-induced knuckle pads have been added to the list of video game-related pathologies. We report… ’PlayStation palmar hidradenitis’ as a cutaneous (skin) pathology induced by console gaming.”

They also recommended that,

“If you’re worried about soreness in your hands when playing a games console, it might be sensible to give your hands a break from time to time and don’t play excessively if your hands are prone to sweating.”

It’s easy to make these recommendations but try telling that to an addicted game player when they are close to achieving that ‘next level’. The medical community does not currently appear to address the addictive nature of computer gaming as well as the resulting conditions. To be honest, I can’t see any way to control this other than extensive education or (more radically) forcing developers to programme in rest breaks to gaming software itself, maybe between levels (you can just see that happening!).

My guess is we will continue to see more and more of these types of injuries and more and more of them will be happening to children who still have a large portion of their computer intensive lives ahead of them. I think that the only way to truly address the problem is to educate parents about the dangers of such gaming systems and their potential for causing repetitive strain type injuries. However, its not just children who are at risk. How many grown adults spend their ‘away from work’ time playing 3-4 hours of video games a night? I’d say a fairly large percentage of the (mainly male) 15-30+ age group.

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There are so many ways today to fritter away huge amounts of our time in our new virtual worlds. Have you ever played a video game and noticed how 3 hours of your life just disappeared?

Technology has brought us immense benefits as a society, but it has also made us slaves to a great extent, and we spend ever increasing amounts of time interacting with devices whether they be computers, mobile phones, PDAs, games consoles, MP3 players, GPS or TV remotes.

A substantial portion of employment now involves working on computers, whether it be the inputting/analysing of data, or the creation of the latest software that controls our lives. The trouble is that, the more high technology we introduce to our lives, the more time we spend interacting with it, often to the disadvantage of our health. It’s not too hard to imagine that, if current trends continue, there will be a technological gadget to interact with from the moment we wake up until the moment we fall asleep (or more scarily from the moment we are born until the moment we die!).

The Web has expanded the information available at our fingertips by a staggering amount. It has also changed the way we spend large amounts of our leisure time (news surfing, watching videos, e-shopping, chatting, talking, sharing photography, socialising, network gaming, browsing) but this has come about at the expense of our health since we are now sitting in a sedentary posture for hours on end making small repetitive movements with our arms, hands and eyes, often in a slouched, bad posture. Before the Internet was available, we obtained our information from books, magazines, newspapers, talks etc which at least involved a walk to the newsagent, library, pub, town hall etc. Socialising was solely done by interacting with people you physically met, and gaming involved running around the public park kicking a football. Nowadays the exercise involved is often no more than climbing out of bed and turning the computer on, and we wonder why obesity rates are spiralling out of control! Not only do we have all this technology available, but we also feel compelled to use it for longer (often hours at a time) in a way that we never did with other more conventional pastimes.

The one thing that all of this technology has in common is that it has forced us to replace lots of big movements with lots of small, repetitive movements, and spend many hours interacting with virtual worlds on a small screen instead of interacting with the real world. It has disassociated us from reality, and made us feel like this virtual world is hugely important, so much so that we can’t imagine life without it. It has led us to be at a heightened risk of developing many types of problems including the very real threat of Repetitive Strain Injuries (RSIs). It has also just as worryingly made serious addicts out of all of us.

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The article indicates that RSI is part of an ever increasing phenomena affecting 115,000 workers last year a staggering 34% increase from the previous year. If ever we needed evidence that RSI is reaching epidemic levels, then this is it.

It also contains a quote from Pauline Cole (a spokesperson for the Association of Chartered Physiotherapists in Occupational Health and Ergonomics (ACPOHE))

“A lot of people are using computers more, even in jobs you wouldn’t traditionally expect it”.

This is the trouble with RSI conditions. Just about every job these days requires interaction with computers, and this can present major challenges when a worker is affected with RSI, there are few options out there to allow them to work whilst avoiding computer use and allowing their bodies to recover, except for perhaps manual labour.

In another revealing quote from the article, this time from Bunny Martin (who runs charity Body Action Campaign)

“schools tend to have a single standard computer set-up for nine and 15-year-olds alike.”, and alarmingly she notes that “around 60% of children she meets have first symptoms of RSI, including strain-related pain in the neck and shoulders.”

This is a staggering fact and if RSI is impacting children years before they start looking for employment then we truly are sitting on a RSI health time bomb.

All in all an excellent summary article on where we are at with RSI.

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