” … 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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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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Repetitive activities, including computer use, can adversely affect more than just the wrist, hands and arms, but also the neck and shoulders. Some years ago, my wife developed a constant and debilitating shoulder problem on her right side. At the end of each day in the office, her shoulder would ache such that the muscles would feel as if they were exhausted. Being right-handed, the most obvious association was with her computer mouse, yet it was apparent that this type of large-muscle ache would most probably not be addressed by using a different, more ergonomic mouse. It wasn’t until she moved jobs and her new desk included a drop down keyboard and mouse tray that the shoulder injury disappeared. Simply lowering the mouse pad had solved the problem. Even today, should she momentarily use a laptop and external mouse on a table top, for example, the shoulder issue will recur.

In addition, the range of occupations potentially affected by RSIs is wide. On several occasions now, I have encountered checkout cashiers wearing tell-tale arm braces which I instantly recognise  as probably indicating an RSI. I have chatted to such individuals and, indeed, they inform me that the repetitive motion of swiping products in front of the barcode scanner has caused their injury. I have recently heard of a tree surgeon having to scale back workload due to pain in his arms from the constant overhead operation of a chainsaw.

Examples of occupations at high risk of RSIs include:

• Journalists, programmers, software engineers – anyone using a computer to do their job
• Construction workers
• Checkout cashiers
• Production assembly line workers
• Machine operators
• Postal sorting workers

Sometimes it is not necessarily repetitive motion that is at fault, but holding the same position for hours on end. For example, many neck problems develop after possibly years of bad posture and/or inadequate breaks whilst staring at a computer screen, or performing any occupation that involves looking downwards (eg a jeweller). Even sleeping is not without hazard, if you are in the habit of lying on your front with your head to one side for example.

Of course, the key words here include “repetitive”, “overuse” and “habit”. The same principles apply in addressing these conditions:

• Awareness
• Good ergonomics
• Adaptive software or hardware (this can include anything from computer mice to chairs to running shoes!)
• Adequate breaks
• Improvement of posture
• Therapeutic exercise such as yoga, pilates etc
• Avoidance, if necessary

So, regardless of whether you are at work or play, upon experiencing the first twinges of pain, it is time to become aware of the cause and to address them accordingly. The choice is yours – you can make the necessary adjustments to your work or leisure habits now, or be forced to give them up entirely later.

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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 is a growing awareness of how much of an impact there is on students. A lot of the ergonomists I work with at different companies have been noticing that students are graduating from college and coming into the workforce already with chronic repetitive strain-injury problems. It seems at least from the anecdotal stuff that it’s important to start focusing more on the student population.”

This could unfortunately be the start of the RSI epidemic wave that I have long been expecting. The younger generation coming through universities and colleges of further education are the ones that have been exposed to ‘technology’ since they were born and have grown up accustomed to a hi-tech life full of computers, mobile phones, gaming systems and other ‘daily use’ gadgets in complete ignorance of the danger that they pose. They are the generation that have grown up with an ever expanding level of text messaging.

What this generation does not appreciate are the dangers associated with RSI type conditions and their implications for future employment (and earnings) prospects. I also wonder whether employers realise the risks of employing people with these conditions, especially into computer intensive jobs. It may not be too far in the future before employers start to check for these conditions during a pre hiring medical examination, although it may be hard to diagnose without honesty from the potential employee.

What is obvious to me is that ergonomic and RSI health awareness training currently aimed solely at employed adults has to be brought into schools, colleges and universities also to educate the future employees before they succumb to a debilitating RSI condition when they start their employed adult life.

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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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In a nutshell, it combines a fairly physical activity encompassing muscle and tendon stretches from your head to your toes, with core conditioning and balance practices. This is coupled with controlled breathing techniques to allow the participant to focus their mind on the present moment. As well as the physical practice, yoga teaches techniques to promote deep relaxation and the ability to clear everyday thoughts from the mind with meditation. This powerful combination really can address a lot of the factors that lead to conditions like RSI (primarily driven by the overused micro-movements of muscles and tendons coupled with bad ergonomics and stressful working conditions).

Yoga practice can

• stretch out abused and injured arm muscles and tendons that have been used in a very poor/restrictive motion for numerous hours
• stretch out your neck, spine, and shoulders which most likely will have also been in a bad posture for hours at work, and can be the sources of a lot of RSI conditions
• enhance the blood flow to fatigued muscles
• enhance overall strength and flexibility
• stretch out tight tendons
• promote relaxation
• promote calmness through meditation
• make the participant feel good about their health
• make the participant decidedly fitter

I have only relatively recently delved into yoga. For those of you who think it’s an activity for girls and hippies, I can assure you it isn’t! It’s really a great practice for everyone and there truly are no age or gender barriers. It can be quite physically involved, which I didn’t realise before I tried it out! I really wish I had started practising at an earlier stage in life while my RSI was not as bad as it is now, when it could perhaps have helped me to address my RSI condition during its early stages.

There are many different types of yoga class out there. The class I currently attend is based on Ashtanga Yoga, and is fairly physical. It involves many stretches (some quite challenging) interspersed with vinyasas* which are physical sequences or “flows” between each Yoga pose. A typical class goes for 1 to 1.5 hrs, and follows a sequence of

• Controlled breathing practice (relaxation, focus of breath and readying self for practice
• Sun salutations (sequences of vinyasas to warm body up with)
• Standing stretch/posture sequences interspersed with vinyasas
• Seated stretch/posture sequences with vinyasas
• Reclined stretch/posture sequences with vinyasas
• Relaxation/meditation.

I can honestly say the time goes by in a flash, and I always leave way more relaxed than before I arrived. It’s a great way to switch off from the working day. The Ashtanga class is fairly physical, and it may be a good idea for you to try to experience yoga at an easier pace first of all, and there are many classes to suit. You can also get many great yoga DVDs these days so you can try it out at home if you prefer (all you need is a yoga mat and motivation!), before jumping straight into a class. I do however recommend trying to aim for a physical version of yoga, since this is what will help you achieve core strength and conditioning, giving your muscles a helpful intensive stretch based workout, coupled with relaxation and the ability to refocus your mind.

It is perhaps the idea of channelling the hyperactivity of the mind into more useful positive energy and thoughts that is one of the key aspects of yoga. If we can control the over activity of our minds, we can achieve a positive state of mind and can face day to day stresses on a more even keel, ie. it can be adapted to many areas of your life. For example, are you perhaps over stressing a lot in the office? Then maybe a 20 min break away from your desk and a bit of controlled breathing and meditation can bring your mind back to a less stressful place, and begin to bring things into perspective, which can’t be a bad thing in these crazy busy lives we now lead now can it?

*”Vinyasa has since been thought of as a physically demanding practice, which can be successful at channelling the hyperactivity of … minds. This system can also be used as a vessel for helping calm ongoing chatter of the mind, reducing stress and teaching extroverted personalities to redirect their attention to their internal experience.” wikipedia

An article from the San Francisco Chronicle highlights the benefits of Yoga practice in the high tech industry.

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Whether this form of computer input technology will ever see serious light of day or not, or whether it will replace the keyboard and mouse, is anyone’s guess, but it is interesting to see trends in technology moving away from using the standard devices (although it is hinted that currently there is no good replacement for a keyboard for text entry).

Whether this technology can save us from RSI related injuries is open to debate; it may well transpire that they just mean we are susceptible to different types of injuries, but it is a good sign that developers are at least rethinking the now traditional methods of interacting with computers. It could lead to opportunities in computer use for people with all kinds of different disabilities, and not just RSI.

Is this the start of a new age in ergonomics, or is it just the latest phase of hi-tech gimmickry ?

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