Repetitive Strain Injury, Overuse Syndrome or Work Induced Upper Limb Disorders

RSI is an increasingly common condition that affects many people. These terms above cover a variety of overuse injuries to muscles, tendons and nerves, predominantly of the forearm, wrists and fingers. Some of the conditions considered to be overuse syndromes, are bursitis, carpal tunnel syndrome, rotator cuff syndrome, tendinitis and tenosynovitis.

Who tends to get RSI?  People who use machines that vibrate constantly, play a racket sport, use a keyboard and mouse, or play a musical instrument. Such activities require repetitive movements of the fingers and wrists, often at speed, for hours on end. However, one pupil told me that her tendinitis came after spending a whole day weeding her new garden! This had involved her twisting and pulling on the weeds in a repetitive way for hours on end.

A report on the BBC news quoted Professor Peter Buckle, University of Southampton, as stating that his research had shown that ‘In some populations that we’ve studied, between 22% and 40% of people have evidence of RSI’. These figures are rising, with approximately 115,000 people in the UK having some form of RSI, which costs the economy 300m per year.

Symptoms of RSI

The symptoms of Repetitive Strain injury are pain, weakness and tingling in the muscles and joints of the fingers, wrists and forearms. These symptoms tend to worsen over time if the condition is not addressed and treated. Initially the discomfort may only be experienced for short periods, during the activity that initiated the condition. This is the point at which changes need to be made in your habitual manner of body Use and probably in your conditions of work, so that some of the damage can be healed and the condition halted before it gets worse.

If someone with RSI ignores the early warning signals and continues to end gain, working or practising in the same habitual way, the pain can gradually become continuous, chronic and disabling. At this point, it may be extremely hard to heal the condition.

Prevention is better – and easier – than cure.

Unfortunately, many people do go on working without addressing the problems they are experiencing. BAPAM (the British Association for Performing Arts Medicine) is familiar with this problem in musicians, who are sometimes afraid to ask for help in the early stages of RSI, in case they are seen as unfit to play and thus lose work. However this unwise decision often leads to severe problems developing and by the time performers eventually seek help, they find they have to stop playing, sometimes for months and occasionally completely.

As Elizabeth Langford so clearly puts it in her informative chapter which discusses how the Alexander Technique can help people with Repetitive Strain Injury ‘You… need to become receptive to warning signals before they become pain, before they become strain, before they become injury’

Elizabeth Langford ~ Mind and Muscle p.209

Causes

The causes of RSI are many and often interact to contribute to the condition. The most significant of these is perhaps the least recognized by the medical establishment: the manner in which we misuse ourselves so that we create movement habits and poor posture that interfere with our functioning and strain our musculoskeletal system.

A young man came to me for Alexander lessons, who had developed pain in the left shoulder. This had developed as a result of trying to teach himself to play the double bass, without having any lessons from a bass teacher or thinking about his body use whilst playing. He was twisting around and lifting his left shoulder, in order to reach over the instrument to the strings. He had also been over-practising and repeating phrases for hours on end, whilst using this tense and distorted position. This sudden increase and over-use of his muscles was bringing about the shoulder pain – and he had only been learning the instrument for one month. Without a change in his use and playing technique, it is likely that he would soon be unable to play because of the pain.

So some of the causes of RSI are:

• Overuse and misuse of the same set of muscles whilst performing the same activity over and again, so that they become fixed and tense and the circulation becomes sluggish. Sometimes this can be linked to feeling ‘bored stiff’.

• An end gaining, perhaps driven attitude towards work, which usually goes hand-in-hand with an intense manner of performance and overuse, along with a reluctance to take short breaks during the working day, let alone holidays. These habits will tend to escalate with high stress levels, so the person’s mind and body cannot unwind and free-up without help.

• Poorly designed or badly placed equipment, or a musical instrument that is held in a way that hampers movement, can contribute to the condition.

• Even with good ergonomically designed equipment, many people still have poor posture and general misuse which contracts muscles and reduces the capacity of the body to function properly. These muscle tensions can irritate the nerves and build up to RSI.

• Over-long working hours and a too-heavy schedule put too many extra demands on people, so that they become exhausted and far less able to take care of their use whilst working and performing.

• Cold temperatures can contribute to the condition – for instance, working whilst sitting under the cold draft from an air conditioning unit.

• High stress levels can result in extra tension and ‘feeling down’ which can interfere with our poise, restrict our movements, create mis-use and sometimes lead to RSI.

In her book ‘Save Your Hands!’ Lauriann Greene describes how she had to give up her career as a massage therapist, because her training had left her with painful RSI. Greene also saw that other therapists had similar problems. This had come about largely because of institutional end gaining, with tutors omitting to consider the means whereby trainees were working.

Greene states that ‘As I read texts on massage, it struck me that the emphasis was always on ensuring the comfort and safety of the client, not the practitioner’ p 4. Greene sees that an important part of helping other massage therapists to avoid such an outcome is to encourage them to work on their body alignment and to notice what is going on in their own body whilst they work, saying ‘Movement centered disciplines like… Alexander Technique teach students how to move their body in less stressful ways to encourage overall health’ and ‘ can be extremely helpful for massage therapists’

Lauriann Greene ~ Save Your Hands! p 105.

Treatment

Medical treatment for Repetitive Strain Injury includes rest, anti-inflammatory medication, pain killers, steroid injections and physiotherapy, all of which treat the symptoms but do little to address the habits of mis-use which usually causes the problem.

The NHS Direct Website also states that learning the ‘Alexander Technique… may help’ and the RSIA Website goes further, saying ‘The effectiveness of the Alexander Technique is well documented and has been the subject of several scientific studies. It is increasingly recommended by doctors, and many medical insurance companies will pay for lessons if these are prescribed by a consultant’.

It is important to remember that no amount of pain killers will actually change the condition for you. Your work situation needs to be altered and you need to learn how to let go of your habits, behaviours and thought patterns that helped cause the condition.  Then a new way of working may be learnt which puts less strain on your body. As can be seen from the testimonial at the end of this article, the use of the Alexander Technique can transform the way a person approaches their work, so that conditions such as RSI can be greatly alleviated.

Some simple self-help tips

A few simple things that you can begin to do which can begin to help RSI, particularly if you are using a computer, are listed here:

• Make sure that furniture, equipment and instruments are well placed and suitable for your body size and movements. Place your monitor at eye height. Sit or stand with an easy, balanced posture.  It can be really helpful to use voice-activated software until you learn how to change the way you compute and work. Perhaps find yourself some different furniture.  Vary the type of mouse you use, so that you use different sets of muscles.

• When using a keyboard, use your arms in as relaxed and easy a manner as you are able, with your elbows at a 90⁰ angle.  Let your feet rest comfortably on the floor, with your knees also at a 90⁰ angle. If necessary use a footrest.

• Take regular short breaks and vary the tasks and range of movements made, to help re-balance muscle usage. Make use of software that monitors your computer use and indicates when it is a good idea to stop for a while. Use your break to move around, let go of tensions and free-up your muscles.

• Most important is to pay particular attention to your body Use and the means-whereby tasks are performed. This is most easily done with the help of an Alexander Teacher. Make sure you are poised, your movements are free and that you resist any urge to being driven, contracted and tense whilst working.

• Take regular exercise such as walking, which will help your general muscle tone and circulation, particularly if you pay attention to the manner in which you walk, so that you avoid creating different patterns of tension and allow your body to work freely as you move. (A workout at the gym may make matters worse if you push yourself too hard and end gain)

• Avoid sitting in draughts and keep warm enough.

Try taking a course of Alexander Technique lessons.  Someone with RSI who is willing to allow themselves to change their way of working can learn how to manage their condition, let go of entrenched habits of misuse, reduce and sometimes even eliminate pain in the process. Maybe you could do this too? I have taught several people who have done just that and importantly, they are also able to use the Technique to help prevent the condition from recurring.

A pupil’s experience of his Alexander lessons enabling him to play music again:

” When I first visited Hilary I was in constant pain and could not even hold a cup of tea, let alone play the guitar. None of the medical professionals I visited had offered me a diagnosis, much less a cure. After my first session the pain was greatly relieved and six months later I’m playing the guitar again, albeit very carefully. I was first introduced to the Alexander Technique at music college and, to be honest, was rather sceptical about it. I now realise that, using it’s techniques, I could well have avoided the RSI which has prevented me from working for almost 6 months. My lessons with Hilary have transformed the way I approach both my music and my health. Apart from enabling me to play again, it has actually improved my instrumental technique and enhanced my enjoyment of music. The Alexander Technique is a very logical, practical tool which enables one to spot potential physical problems and find solutions which can be easily incorporated into a daily routine. I would recommend both Hilary King and the Alexander Technique to anyone, but especially musicians, including those who are seemingly healthy. Quite simply, it will make you a better musician and a healthier human.”

Carpal Tunnel Syndrome (CTS) comes about if the sensitive median nerve is compressed as it passes from the forearm through the narrow space of the carpal tunnel in the wrist, before entering the hand. The size of the carpal tunnel is variable, it is a rigid structure which also houses the nine tendons which bend the wrist and fingers. So space is limited and if the tendons are tense and swollen from overuse, they can irritate or put pressure on the nerve.

Carpal Tunnel Syndrome is often included under the umbrella term of Repetitive Strain Injury. Women are more prone to the condition than men and it is mainly found in people aged between 40 and 50.

Symptoms

The symptoms of carpal tunnel syndrome can affect one or both hands and include pain, numbness and tingling in the thumb and three fingers. The little finger and the outside of the fourth finger are not affected. The pain sometimes radiates up into the forearm and may be worse at night, or during specific activities such as driving, where the steering wheel is often held with great tension, with the wrist bent at an angle.

CTS is progressive, and as impulses gradually reduce in the median nerve, there can be a loss of sensation, then weakness in the thumb with a resulting loss of grip. People with the condition may lose some manual dexterity and experience some clumsiness when carrying out tasks which require fine movements, such as playing a musical instrument or sewing.

Causes

There are many factors which can contribute to the median nerve being compressed. Some of these you can have some control over and would be wise to avoid, so that you look after your hands. Many of these habits of mis-use are subtle, hard to recognize and change but this process would be made easier with the help of an Alexander Teacher.

Some of the causes of CTS are:

• Activities which require constant flexion and extension of the wrist can lead to a build up of fluid within the carpal tunnel, which creates congestion, putting pressure on the median nerve. If such movements are done with tension and mis-use, or the wrist is held for long periods of time bent at an angle, for instance whilst pushing a heavy pushchair, the pressure on the median nerve will be increased.
• Working with a negative attitude, or a tendency to be driven, will increase the likelihood of such tension and mis-use.
• The combination of flexion, plus pressing the wrist onto a hard surface such as a desk whilst computing, can be particularly damaging.
• Constantly vibrating power tools can cause carpal tunnel syndrome and this is a recognized industrial injury.
• Pregnancy, obesity and conditions such as diabetes may also cause water retention in the wrist.
• Arthritic conditions, fractures and dislocation of the wrist can cause inflammation and swelling.
• Hormonal changes that occur during the menopause, with thyroid problems, or with the combined contaceptive pill, can contribute to the condition.
• Cysts or swelling of blood vessels and tendons are likely to cause congestion and inflammation.
• Bending and contracting down over work surfaces such as a desk, so that extra weight and pressure is put on the hands and wrists.

It is possible for similar neurological problems to be experienced in the hands as a result of certain diseases, from lesions, or pressure being put on the upper section of the median nerve in the neck or the brachial plexus. Such problems may come about, for instance, after accidents or from poor posture and general mis-use. For instance, holding the neck forwards with tense, rounded shoulders, which can put pressure on a variety of nerves.

Wrists, when flexed for long periods, can compress the median nerve

Prevention’s better than cure

Prevention is always better than cure, so being aware and looking after the way you use yourself whilst performing tasks, may help you avoid carpal tunnel syndrome or other forms of RSI altogether.

You can begin by asking yourself, what is your attitude towards work? Why are you so tense – are you stiff with boredom? Or are you intense, always on edge, perhaps feeling driven, so you think you need to work harder and faster than others, without taking any breaks? If so, observe how much pressure you put on yourself mentally and physically. How do you use your hands, wrists and arms – do you recognize how much tension you create in them? Maybe you don’t need to live and work like that.

Take regular breaks and use them to calm down, undo the tension in your arms and allow your wrists to freely lengthen as much as possible. Try out a wrist support and see if it helps reduce the pressure whilst computing. The more aligned and poised you are when you work, the less of a downward drag and pressure will be put on your arms, allowing them to move more easily. If your furniture and equipment is hampering your ability to work in a poised manner, make sure some changes are made so that you have a chance to look after yourself. If you can no longer find a way of freeing-up, then you would be wise to seek the help of someone like an Alexander teacher who can work with you on these issues.

If CTS does begin to develop, the sooner carpal tunnel syndrome is recognized and action is taken, the more possible it is to stop the condition from getting worse. Left untreated, there can be permanent damage to the median nerve.

Treatment

Medical treatments for carpal tunnel syndrome generally treat the symptoms, not the cause and may include: anti-inflammatory drugs, cortico-steroids and ultrasound to reduce pain and inflammation; diuretics to reduce water retention; in severe cases, surgery is possible. Physiotherapists may provide wrist splints, to rest the wrist and maximize the space in the carpal tunnel and they may also teach patients some finger exercises. If someone is obese they will be encouraged to lose weight, in order to reduce fluid retention and therefore put less pressure on the median nerve.

Sometimes, temporary relief may be found by massaging or shaking the hand, which will free the wrist for a while. However, if the underlying causes are not addressed, the pain will return.

In Alexander Technique lessons, we do not treat people but pupils are helped to become aware of their general thought patterns, tension, poor posture and mis-use that generally underlie the causes of CTS and other conditions. Someone with CTS could also be helped to recognize and let go of, any specific habits that involve holding the wrist at an angle, which would irritate the condition. In this way the pupil can begin to modify the way they move and their perceived need to work so intensely, for instance. As a result of these changes, they will begin to free up their muscles and avoid compressing the median nerve.

If we take the example of a guitarist who has a habit of bending the wrist acutely whilst plucking his instrument, this could compress the median nerve and cause carpal tunnel syndrome. Such a manner of playing often goes with the guitarist curling down over the instrument somewhat intensely, in order to see his hands, to make sure he gets it right. This downward thrust can put pressure on muscles and nerves in the neck and shoulders, plus create a twist in the torso, all of which could contribute to other problems and interfere with his playing.

An Alexander teacher would help the guitarist to become aware of such habits and attitudes, so that he could learn to inhibit them. This would take time but would be very worthwhile. He would gradually become calmer and more poised, allowing his arms and wrists to be free and less angled whilst playing. These changes would help reduce the pressure on the median nerve and thus the pain of CTS. It would also enable his arms to move around his instrument more freely and fluidly which will surely help his music making.