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Constructive Programme for Repetitive Strain Injury

by Darren Tilley(more info)

listed in bodywork, originally published in issue 163 - October 2009

Five years ago, I had pain. My wrists were so painful I could think of little else. My career was dependent upon being able to use my hands; I couldn't pick up the lightest weight without jagged pain forking down my forearms. I couldn't apply the softest pressure with my fingertips without feeling like someone was twisting white hot skewers into my wrists...

Darren Tilley
Darren Tilley

I had RSI... or was it carpal tunnel syndrome, maybe it was median tunnel syndrome? Who knows...

The fact was, I was four years out of graduating as an Osteopath. I'd specialized in soft tissue manipulation and was building a very successful practice using the skills I had developed. Unfortunately, those skills required that I spend the majority of my day working deeply into people's muscles and connective tissue, using my fingertips and thumbs, often at angles and pressures that simply didn't allow for the perfect posture or hand position (on my part). It seemed I was paying the price for this kind of work, with pain, misery and the potential loss of my livelihood.

If you are reading this and have similar problems, I ask you not to give up hope.

Five years down the line, my practice is even more successful! I provide for all my family's needs and live a comfortable happy life; we holiday regularly and have a lovely home. My point in telling you this is to illustrate that in order to achieve these things I've been treating even more people than I was five years ago. My hands and wrists don't give me a moment's trouble.  In fact, they are stronger than they ever were, and I healed my so called RSI whilst I was working!

This article is designed to show you, and perhaps help you achieve the same thing, either by yourself, or with the help of a therapist who understands this process.

But let's go back to the beginning. RSI or repetitive strain injury, is not the sole province of Body Workers, be they Massage Therapists, Sports Injury specialists, Chiropractors, Osteopaths, Physios or any other kind of hands on practitioner. Repetitive strain can be experienced by anyone who does a repetitive job with their hands. Maybe you're a waitress or a typist, an electrician or a carpenter, or perhaps some kind of line work in a factory requires that you do the same thing day in and day out with your hands?

Repetitive Strain Self-Help Massage
Petrissage into deep pectorails muscle fibres
Petrissage into deep pectorails muscle fibres
Dry massage creates deep tissue separation in forearm
Dry massage creates deep tissue separation in forearm
Firm fingertip massage into scalene muscles
Firm fingertip massage into scalene muscles
Quick wrist flexion can induce muscle fibre separation
Quick wrist flexion can induce muscle fibre separation

The fact is anyone who does a repetitive job could end up with the symptoms of RSI. But before we go onto what those symptoms are, let me ask you something: – If Repetitive strain injury is caused by repetitive strain, why doesn't everyone doing this kind of work repetitive work succumb to it? Think about it, millions of typists in the world, all doing the same kind of work; why do only a very small percentage of those people suffer from RSI? Could it be that Repetitive stress is not the primary cause of these symptoms? Maybe there are other factors involved...

This possibility is essentially the crux of my approach to treatment. I don't argue that this is the only approach, but certainly one that should be considered.

So lets get back to the symptoms,  Let's assume you have some kind of repetitive job, hobby or sports activity. You find that initially you have an uncharacteristic ache in your wrists or hands while working. You find yourself frequently stopping to rest and rub the aching areas. The moment you stop what you're doing, the pain disappears. You don't really pay much attention, it's a slightly inconvenient problem, and anyway there's no discomfort when you're not working, it's nothing serious. We could call this Stage One. This would be the ideal time to consider having some assessment and treatment, but most people won't feel there is enough of a problem to warrant the effort of seeing the doctor or finding a reputable therapist. So, in the same way a fly gently slides down the walls of a bug eating plant... they'll gently slip unknowingly into Stage Two.

As Stage Two creeps insidiously upon you, the initial symptoms are becoming more intense, although, strangely you may have days where they seem almost absent. You are noticing as well, that your neck can be quite stiff, sometimes your shoulders or arms also ache, there maybe discomfort between your shoulder blades. But mostly you begin noticing that occasionally the ache in your wrists or hands is becoming more of a pain, there may be some mild signs of tingling, pins and needles or numbness. You start to wonder if you should see a doctor or someone...

If you don't find the right person to help you, or learn how to help yourself and you continue with the same activities, then Stage Three will kick in as sure as the tide rolls up the shore. The aches have progressed to much more intense pain in the form of stabbing, burning or more constant gnawing pain; you may experience painful tingling or complete numbness on occasions.  These symptoms may be general or specific to certain fingers or areas of your hands, wrists or forearms. Emotionally you are tired of it, work requires twice the energy and concentration, and each morning is a draining source of apprehension about the pain you know you are going to experience today. If it is a hobby, you've already given it up; because you've now lost all the enjoyment you previously associated with it. You have definitely seen a doctor or therapist, you are probably wearing some form of wrist brace, maybe a magnetic or copper band or something else. You are scared because you can now see that this could actually mean you are unable to do your job. The misery you are experiencing will now enhance the discomfort. You are looking at any and all approaches to try and ease the pain. 

The above stages are my own interpretation of RSI progression, based on my own experience and those of many of my patients. Different authorities may cite more or less stages, and may note more specific symptoms of each stage. But generally, I have described the gist of it.

Typically, your doctor will examine the area of pain, your hands and wrists. He or she will perform certain tests designed to highlight nerve or blood vessel pressure in this area, and depending on the history you presented, along with the results of the tests, he will provide a diagnosis. If the tests and symptoms suggest a lack of space and increased pressure on the nerve route into the hand through the wrist, the diagnosis is likely to be carpal tunnel syndrome or something similar.  Occupational activities are usually cited as the cause. If ergonomic factors within the workspace have been addressed with no improvement, as is often the case, then the doctor will sometimes recommend you change your job. They may also prescribe physiotherapy or support braces. Ultimately, if there is no improvement, they may suggest surgery.

The diagnosis may make sense, except for one thing, why doesn't everyone get RSI? What made you susceptible? Are you really the only one who slumps in their work chair? Are you really the only one who doesn't have a perfect height desk, with chair and monitor ratios and angles to suit?

There is no doubt at all that these factors need to be considered; it would be foolish to think they don't. If you work at a computer you need to consider ergonomics. Most office workers are aware of these factors and certainly most employers are. If you are a Body Worker, you also will be aware of the importance of weight distribution and efficient technique, particularly how you use your hands. Yet RSI symptoms can evolve and persist.

So how did I resolve my RSI symptoms, without rest, and without substantially changing the way I work?  I did so by believing and employing the following principles:-
  1. That the body is capable of withstanding just about any normal 'repetitive' activity, as long as the tissues involved in performing the activity are healthy and have full and normal blood and nerve supply. (Clearly 'normal' is open to interpretation when it comes to repetitive activity, but if the majority of people performing that activity can do so without developing RSI, then it's reasonable to consider that the problem lays within the individual rather than the activity.)
  2. More often than not, if nerve or blood supply is compromised, it is by dysfunction within the body's most sensitive and reactionary structural soft tissue, muscle, closely followed by connective tissue tensions.
  3. The results of these dysfunctions and inappropriate tensions lead to inflammatory reactions, eventually followed by chronic adhesions between various tissues including fascia, muscle and nerve tissue.
  4. Points two and three can be resolved by the judicious use of massage techniques and certain exercises and stretches, as long as massage is the primary therapy.
So when we consider our symptoms, let's say wrist pain for simplicity's sake, and take into consideration point number one. We could make this analogy: The muscles in your forearm are an electric motor, your central nervous system (CNS) is the power supply, and your nerves are the wires carrying the power.

So, your forearm motors require 240 volts to function properly, and as long as they get 240v they can pretty much deal with any repetitive activity you throw at them. Now imagine the power supply is compromised. The power generator (your CNS) is fine, but the wires to the motor have some pressure upon them, affecting their ability to carry full power. The motor is now only getting 210v instead of 240v. It still works, but it doesn't work quite as well or as efficiently... Gradually repetitive action becomes repetitive strain, then injury.

The above analogy could be a description of a condition known as Thoracic Outlet Syndrome, or TOS.  Quite simply, several areas in the structure of the neck, shoulder and chest have the ability to become over tight in response to various factors including posture, sleeping position, injury and emotional stress. This in turn can put pressure on the nerve supply to the muscles in the shoulder, arm, wrist and hand.

More often than not, dysfunctional changes within the thoracic outlet area are symptom-less even as they apply pressure to the arm's nerve supply, but the muscles supplied by the compromised nerves cannot respond effectively to sustained repetitive actions, and begin to display symptoms of fatigue. This can be made all the worse by poor posture or technique. Mild inflammatory reactions occur in response to the irritation of these muscles,  and over time,  inflammatory build up begins to turn viscous, then glue like, finally creating adhesions between adjacent tissues, causing even more, local dysfunction, and more inflammation. Welcome to RSI.

So, what can you do? What did I do? I can tell you, I tried almost everything. Massage of my painful wrists and forearms, (a tall order when the hand you are using to massage your other forearm is burning with pain!) I tried gels and creams, I tried herbs. I tried Acupuncture, Sports Massage, Osteopathy and Chiropractic, I tried stretching and finally I tried rest. The lowest I got emotionally after all this was when at the end of ten days complete rest, my very first attempt to lift the head of my first patient of the week, caused a pain like ragged burning claws being drawn through the skin of my wrists by some malignant entity wanting to rip my current lifestyle away from me.

As I wallowed in daily despair, a book by Suparna Damany [1] became part of a series of events that led me to understand the importance of TOS in my condition. Despite having no symptoms whatsoever in my neck, chest or shoulders, I began to use my painful hands to start massaging the main TOS hot spots, these being the scalenes and the pectoralis minors.  I found them to be astonishingly tender to pressure (as dysfunctional muscles almost always are).

Concurrently I started doing a series of exercises known as the 'Five Tibetans'. [2, 3] I found these to be excellent for helping to open the areas that I was freeing up through massage, in the thoracic outlet zones.

Five Tibetans
Opening up thoracic outlet with Tibetan rite postures
Opening up thoracic outlet with Tibetan rite postures
Opening up thoracic outlet with Tibetan rite postures Opening up thoracic outlet with Tibetan rite postures   Strongly opening and stretching the thoracic outlet tissues
Strongly opening and stretching the thoracic outlet tissues
Creating movement in posterior, and space in anterior neck muscles
Creating movement in posterior, and space in anterior neck muscles
Strengthening anterior, and stretching posterior neck muscles
Strengthening anterior, and stretching posterior neck muscles

Something else that seemed to have a measurable effect on the improvement of my symptoms was the use of dumbbells; it had almost started as some kind of anthropomorphic demonising of my wrists and a desire to 'punish' them for the misery they were causing me...  I still hesitate to recommend this to patients, but will describe it to you anyway, because of the improvement I attribute to it.

Using dumbbells that were just on the heavy side of comfortable, I rested the back of my forearm on my thigh whilst sitting, and allowed the dumbbell to pull my wrist down into a fully extended position. I then forcibly and rapidly pulled it into a fully flexed position. It was painful, but in that good way often described as good or grateful pain. I had a vivid picture in my mind of adhesions between muscles and nerves and fascia being forced apart, allowing these tissues to move effectively again. At the time I attributed the characteristics of isolytic release techniques to this effect (as described by Leon Chaitow in various texts, but particularly understandable in this book). [4] I did the same thing in reverse, resting the flexor side of my forearm on my thigh and rapidly forcing the wrist into extension with the weight of the dumbbell in my hand. I recommend you take professional advice before using this technique.

Finally, I continued with the massage of my forearms, my hands and my upper arms, as well as the tender thoracic outlet tissues. If the area was very tender, I used oil to facilitate movement of my fingers and knuckles over the skin, then as it became less tender, I stopped using oil and worked 'dry' using the friction between my fingers and the skin the create deeper shearing effects into the fascia and deep muscle tissue. (I use this approach now in most of the soft tissue work I do).

There are two other factors that I employed in my recovery, one of which, I almost always recommend in the first instance to patients who are suffering from RSI symptoms, and that is the use of night splints. I am not an advocate of wearing splints or supports during the day, no matter how painful your symptoms, but night splints almost always have a beneficial effect, by reducing the irritation and inflammation caused by the extreme wrist flexion and extension experienced by most people during sleep, and which of course is particularly aggravating to people with RSI symptoms.

The other factor is magnetic bracelets. My interpretation of the various theories of its action is that positive changes in red cell clotting caused by the magnetic field, allow those cells to penetrate more effectively into the arterioles of stressed areas, thereby increasing oxygenation of those tissues and reducing pain. My feeling is that the magnetic field does little to change anything permanently and can even be a negative factor if it allows the underlying causative factors to go untreated. I say this because my personal experience and that of many patients who have used magnetic therapy is that symptoms which may have eased, very soon return when the magnet use is discontinued. Nonetheless a reduction in pain during the process of self treatment can be very beneficial.

Over a period of three or four months, my symptoms gradually decreased, I'd somewhat adapted my techniques for working, using my elbows and knuckles, but it wasn't perfect, and the gradual realization that my hands and wrists were becoming less and less painful to use was like a golden wash of summer sunshine after a particularly harsh, cold and painful winter.

For me, RSI was to become a thing of the past, and a monster that I no longer fear.

References

1.    Suparna Damany, MSPT & Jack Bellis. It's not Carpal Tunnel syndrome! RSI theory and therapy for computer professionals. Simax publishing, Philadelphia. ISBN 0-9655109-9-9. 2000.
2.    Peter Kelder. Ancient secret of the fountain of youth. Doubleday publishing, New York. ISBN 0-385-49162-x 1998.
3.    Christopher S. Kilham. The Five Tibetans: Yoga Methods of Power. Publisher: Inner Traditions Bear and Company. ISBN-13: 978-0892814503. May 1994.
4.    Leon Chaitow. Osteopathic Self Treatment. Thorson publishing. Wellingborough. UK.
ISBN 0-7225-1477-8. 1990.

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About Darren Tilley

Darren Tilley DO found that many years of martial arts practice had led to many injuries and many visits to an Osteopath during the second two decades of his life. The extreme use that he had put his body through, combined with a fascination of how therapy could relieve his pain was the impetus for him to train and qualify as an Osteopath in the late 90s.

His own experience with therapy was of soft tissue manipulation always being more profoundly effective than joint mobilisation ever was. He worked with classical Osteopathy initially, then began to specialize in soft tissue manipulation, constantly building on what he had learnt at college. He found that he became particularly effective at dealing with more chronic conditions, often where previous practitioners had struggled using classic techniques.

Darren continues to use his own aches and pains, as well those of his patients, as a learning process, and he is constantly evolving the way he works with soft tissue to resolve chronic issues. He believes our muscles are a reflection of our existence on multiple levels including physically, emotionally and chemically and therefore, understanding and working with them effectively can create profound, positive and lasting changes within an individual.

Although his excellent osteopathic training remains the fundamental basis of how he works, he decided some time ago that he did not require the umbrella of the Osteopathic Council and so he remains unregistered.

Darren Tilley may be contacted via  dstilley1@yahoo.co.uk   www.darrentilley.com

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