“Dr Irena” Health Tips – No. 21

Repetitive Back Strain

Irena Hulson is continuing with her series of health tips, which have been very well received by our readers, especially those who can relate to certain of the topics covered and we hope to receive and publish more in the future for your information.  If there is a particular topic you would like to see published please let us know and we will ask Irena to see what she can find on the subject.

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By Irena Hulson

(Courtesy of Emil Pascarelli and Debra Quiller – extract from their book)

REPETITIVE STRAIN INJURY  (RSI)

In simple medical terms, repetitive strain injury (RSI) is defined as a cumulative trauma disorder (CTD) stemming from prolonged repetitive, forceful, or awkward hand movements. The result is damage to muscles, tendons, and nerves of the neck, shoulder, forearm, and hand, which can cause pain, weakness, numbness, or impairment of motor control.

You may wonder how seemingly innocuous activities such as typing and clicking a mouse button could possibly be harmful. Fine hand movements, repeated hour after hour, day after day, thousands upon thousands of times, eventually strain the muscles and tendons of the forearms, wrists, and fingers, causing microscopic tears. Injured muscles tend to contract, decreasing the range of motion necessary for stress free work. The sheaths that cover delicate tendons run out of lubrication because they aren’t given time to rest, so tendon and sheath chafe, resulting in pain. Due to this abrasion, tendons become inflamed, and begin to pinch neighboring nerves. This can result in numbness, tingling, or hypersensitivity to touch. Unless this cycle is interrupted, it repeats itself over and over, and a long-term, chronic problem results.

Repetitive strain injury can affect more than just your hands and wrists. Poor posture can lead to severe neck and back injuries. Staring at a computer screen can lead to eyestrain. Repetitive reaching for a mouse can lead to arm and neck strain as well as spinal asymmetry.

RSI is not a specific medical diagnosis, but rather a family of disorders. Many people mistakenly equate RSI with carpal tunnel syndrome, even though CTS is only one particular form of RSI. One recent study even reported that frequent computer users are no more likely to develop CTS than non-computer users. Don’t let this mislead you, though. Many other forms of RSI do come on as a result of frequent computer use.

Who is at risk?

The three primary risk factors are poor posture, poor technique, and overuse.  In addition to these, there are several other risk factors to be aware of. While they may not cause RSI on their own, they can increase your risk if you already possess one of the three primary risk factors.

• Have poor posture
• Have poor technique
• Use a computer more than two to four hours a day
• Have a job that requires constant computer use, especially heavy input
• Don’t take frequent breaks
• Are loose-jointed
• Don’t exercise regularly
• Work in a high-pressure environment
• Have arthritis, diabetes, or another serious medical condition
• Keep your fingernails long
• Have an unhealthy, stressful, or sedentary lifestyle
• Weigh more than you should
• Don’t sleep well
• Are afraid to ask for better accommodation
• Won’t accept that you are at risk when you really are

What are the symptoms of RSI?

The primary warning sign of RSI is pain in the upper extremities (fingers, palms, wrists, forearms, shoulders). The pain may be burning, aching, or shooting. It could be local (e.g., fingertips) or diffuse (e.g., the entire forearm). The pain will typically be increased after a long session of computer use. Keep in mind, however, you can have severe RSI without experiencing pain. Avoid using the injured hand?

• Use your non-dominant hand more frequently?
• Use your forearm, feet, or shoulder to open doors?
• Avoid wearing or buying certain kinds of clothing because it is too difficult to put them on?
• Change shopping habits because you can’t carry as much as you once could?
• Keep dropping things?
• Find you can’t chop food?
• Not play sports you once enjoyed?
• Have trouble hooking bras or putting on jewellery?
• Not wear bracelets because your wrists are tender?
• Have trouble with keys or brushing teeth?
• Feel overly protective of your hands?

Repercussions of RSI

If you develop RSI, and do not take steps to correct the problem, there may be serious repercussions. When my RSI was at its worst, I was unable to open doors, prepare my own food, do laundry, drive, write, type, and shake hands. This lasted for half a year. I was unable to type regularly for about three years. Many RSI sufferers complain of similar problems. In addition to limiting your day-to-day functionality, this decreased independence can cause a significant emotional burden.

RSI can limit your ability to perform at work. Recent Supreme Court rulings do not view RSI as a disability, and hence, RSI is not covered under the Americans with Disabilities Act. (Apparently typing is not a “major life activity,” according to a recent opinion authored by Sandra Day O’Connor, for those whose job requires significant amounts of typing.) Therefore your employer may fire you if you are unable to perform your job because of your RSI. The prospect of changing (radically, in many cases) your profession is obviously a daunting thought. For students, most universities are willing to make accommodations, but lost productivity due to RSI could still delay your graduation one or two years. And once you graduate, your next employer may not be as accommodating.

When you first notice symptoms of RSI, you have already done substantial damage to yourself. RSI can take months, even years to develop, and you can expect it to take at least twice as long to heal. It has been several years since my RSI was at its worst, and even now I must limit my typing. Even if you feel no pain or other symptoms of RSI, you would do well to heed the following advice for RSI prevention, especially if you meet one of the risk factors outlined above.

Good posture is crucial

What is good posture? For our purposes here, good posture is when you are seated in such a way that the effort required to work at your computer is minimized. The following checklist identifies the proper way to sit in order to achieve good posture:

• Feet: flat on the floor
• Knees: directly over feet, bent at right angles (or slightly greater), with a couple inches of space from the chair
• Pelvis: rocked forward, sitting on the “sitz bones,” with hips (the sockets where your femurs attach) positioned no lower than, and perhaps slightly higher than the knees.
• Lower back: arched in, and possibly supported by your chair or a towel roll.
• Upper back: naturally rounded
• Shoulders, arms: relaxed, at side.
• Neck: arched in, relaxed, supported by spine. Be careful not to hold tension in back or under chin.
• Head: balancing gently on top of spine.

There can be exceptions. For example, it’s OK to shift your legs and feet around if they get fidgety, but be sure to always keep the spine neutral and the head balanced above the pelvis.

Unfortunately, the above written description can be very difficult for some people to actualize. Over the course of our lives, our bodies become so habituated to certain patterns of muscle tension, that we are unable to accurately perceive ourselves. For example, I may feel like my spine is in a neutral position, when in fact my lower back has too much arch. Even if I were to show you pictures, that would not solve the problem because (1) the difference between good and poor posture can be subtle, and (2) even if I could perfectly describe proper posture to you, your brain may not have the ability to accurately put your body in that position, because of the aforementioned habitual patterns. One solution to this dilemma is to have a skilled teacher re-educate you on postural awareness. This can be done by someone trained in a form of “bodywork” such as the Alexander technique. Another strategy is to regularly practice gentle yoga or other practices that enhance mind-body awareness.

I believe that your posture at your workstation is the most important factor in determining your risk for RSI. Moreover, in my experience, your chair is a major determinant of your posture. I cannot overstate this. Sitting at a workstation entails holding your body in a static position (described above) for long periods of time. Holding yourself in this position puts strain on your muscles. The less support you receive from your chair, the more strain is placed on your body. Therefore, it is essential to have a chair that supports you as well as possible.

The key to a good chair is adjustability. A good chair will be adjustable in the following ways:

• Height of seat
• Angle of seat
• Height of backrest
• Angle of backrest
• Seat slides forward or backward
• Arm rests move up/down and in/out

It is also important to have a firm seat, so that your pelvis can be firmly grounded, but not too firm, so that your rear isn’t killing you after a short time. Be careful to avoid chairs with a bucket seat, i.e., a seat that makes your pelvis rock back. Tall people will prefer a chair with a high backrest. A head/neck rest should not be necessary, since your head should be balanced over your spine. Wheels are also nice, if you have a carpeted floor, although wheels on a wooden floor may slide around too much. The seat pan should be long enough such that the space between your calves and the end of the seat pan is about two finger-widths. If you are tall, you may need a chair with an extra long seat pan. Highly adjustable chairs can be expensive, costing several hundred dollars. I got my chair at a discount (~$700) through the Ergonomics Office at my university. Check with your employer’s ergonomics office, to see if you can receive a similar discount. If you can afford it, a good chair is definitely worth the investment, and the higher the quality, the longer it will last you. A well made chair should last 20 years or more. But be careful when purchasing a new chair: many models say they are ergonically designed, but are not. Be wary of less expensive models sold at box stores; you will get what you pay for. I recommend that before you buy a chair, you do two things: (1) Use the chair for a week to make sure it fits you (your ergonomics office may have a loaner program.),

In this section I offer some specific recommendations for stretching and strengthening exercises that have helped me. These fall under the category of prevention as well as recovery.  Most of them you can easily do in your office during breaks, which you should take every hour or so.

Wall stretch: This is my favorite stretch. It is great for stretching out the shoulder, arm, wrist, and hand all at once. Extend the arm along a wall, with arm parallel to the ground and palm facing wall. Attempt to open chest so that shoulders are perpendicular to arm. Extend fingers and palm away from wall as much as possible. Your hand may tingle – this is OK. Hold for 30-60 seconds. Try with the arm at different angles. Repeat on other side.

Doorway: This stretches the pecs and shoulder. Hold elbow at a right angle, and place forearm along door frame, as shown. Lunge forward, keeping chest and pelvis facing squarely forward. Hold 30-60 seconds. Try holding arms at different angles. Repeat on other side.

Back and neck strengthening: The other thing I do that really helps is an exercise that involves one of those big exercise balls, a long dowel rod, and a couple of 3 (or 2) pound dumbbells. You get on your knees, lay your chest on the ball, put the rod on your back so that it makes contact with your rear, back, and head (to keep the spine neutral). The ball should be big enough so that the rod is sloping slightly up. Then just slowly raise the dumbbells off the ground and lower back down. You can have the arms at different angles, but start with them extending behind you, as that is easier. Also try turning your head from side to side occasionally as you go, to activate the neck muscles. You do not need heavy weights for this exercise to be effective, and heavy weights may in fact strain your already fatigued muscles.

Correct breathing: It’s amazing how stress and computer use can corrupt our natural way of breathing. I highly recommend Barbara Conable’s short little book on breathing called The Structures and Movement of Breathing: A Primer for Choirs and Choruses . Don’t worry that it is written for choirs, there’s a lot of useful info for everyone.

Eye palming: A relaxation technique for the eyes is to place your fingers crossed over your forehead and cover the eyes with your palms. Do not apply pressure to the eyeball. Just concentrate on the blackness for a while. Another simple but great technique is to just look out the window at a distant scene.

The above exercises are geared toward relieving/preventing the symptoms of RSI. If you want to eliminate the root causes of RSI, you must focus more on stretching, strengthening, and re-educating the core muscles of your body responsible for maintaining proper alignment and posture. It is not possible for me to explain how to do this here. However, there are several practices/techniques that aim at this goal, including Yoga, Pilates, Alexandra technique,  and Thai Chi. You can probably find a group class in your area if you live in a large city or near a University. Yoga and Pilates can also be learned from books and videos, but it is usually better to learn from a teacher and to practice with a group. Personally, I have derived benefit from yoga, Pilates, and especially the Alexandra technique

Ten easy ways to reduce your risk of developing RSI

1. TAKE BREAKS! when using your computer. Every hour or so, get up and walk around, get a drink of water, stretch whatever muscles are tight, and look out the window at a far off object (to rest your eyes).
2. Use good posture. If you can’t hold good posture, it probably means it’s time for you to take a break from typing. If you are perpetually struggling to maintain good posture, you probably need to adjust your workstation or chair, or develop some of the support muscles necessary for good posture.
3. Use an ergonomically optimized workstation to reduce strain on your body.
4. Exercise regularly. Include strengthening, stretching, and aerobic exercises. I find yoga and Pilates especially helpful.
5. Only use the computer as much as you have to. Don’t email people when you could walk down the hall or pick up the phone and talk to them. It’s not only better for your hands – it’s friendlier. Think before you type to avoid unnecessary editing.
6. Don’t stretch for the hard-to-reach keys, e.g. BACKSPACE, ENTER, SHIFT, CONTROL… basically everything but the letters. Instead, move your entire hand so that you may press the desired key with ease. Let your hands float above the keyboard when you type, and move your entire arm when moving your mouse or typing hard-to-reach keys, keeping the wrist joint straight at all times. This lets the big muscles in your arm, shoulder, and back do most of the work, instead of the smaller, weaker, and more vulnerable muscles in your hand and wrist. If you find it difficult to do this, then your shoulder and back muscles are probably too weak. It is OK, and in fact a good idea, to rest your elbows/wrists when you are not typing.
7. Use two hands to type combination key strokes, such as those involving the SHIFT and CONTROL keys.
8. When writing, avoid gripping the writing utensil tightly. Someone should be able to easily pull the writing utensil out of your hand when you are writing. If your pen or pencil requires you to press too hard, get a new one (my favorite is Dr. Grip Gel Ink)
9. Realize that you are not invincible. RSI can happen to you. Don’t be afraid to ask for help.

If you develop RSI

Be prepared to make some changes in your lifestyle and your computer habits. In particular, make an extra effort to follow the guidelines laid out in the previous section on prevention. Following these guidelines can decrease your recovery time, and help you avoid relapses in the future.

STOP TYPING!(?)

Very few people have the luxury of being able to avoid typing altogether. However, if you think carefully, you’ll find there are many ways to eliminate unnecessary typing from your life. For example, instead of sending e-mail, use the phone, or better yet, get out of your chair, walk down the hall, and speak face-to-face to the person. Drop out of your fantasy baseball league. Rely on newspapers and books for information, and stop surfing the Web so much. Instead of playing solitaire on the computer, buy yourself a real deck of cards, and play it the old-fashioned way. Just check your email twice a day. Et cetera. In general, eliminate unnecessary computer use from your life. And a whole lot of it is unnecessary. It may seem like a sacrifice, but your health is worth it.

One technique I use is the following: when I am at my office, throughout the day I use an index card to record all of the e-mails I wish to send. I keep the index card in my back pocket. Then as soon as I get home from work, I will use my dictation software to compose all of the e-mails in one sitting. This has many advantages: it saves me from the tendency to type quick e-mails with my hands while at work; I am less distracted by e-mail at work; if you don’t respond to an e-mail right away, sometimes the need to ever respond goes away; once people learn that you don’t respond to e-mails right away, they send you less e-mails.

For typing that you just can’t avoid, consider using voice activated software or arrange to have someone type for you.

Editor’s Note

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