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Newsgroups: bit.listserv.c+health
Date:         Wed, 9 Sep 1992 20:25:59 BST
From:         Richard Donkin <richardd@HOSKYNS.CO.UK>
Subject:      Adverse mechanical tension
Comments: To: c+health <C+HEALTH@IUBVM.UCS.INDIANA.edu>

I've received a few requests for info on adverse mechanical
tension (AMT), so I thought I'd post this to the SOREHAND and C+HEALTH
lists.

This is very long, but my aim is to pull all the relevant info together,
and gather comments, before turning this into a file that can be
accessed from Bitnet and Internet file servers.

Apologies to those who are already aware of this, but there is no published
info that I am aware of.  Apologies also to those who get both lists!

I am not an expert on AMT (and nobody yet uses this acronym that I've
heard!)  However, I can relay some info from Wendy Chalmers-Mill, a
physiotherapist with 5 yrs experience of treating RSI.  She has
very definite views, which are probably pretty close to correct,
but there is not very much consensus in RSI.  She has worked for most
of this time with Richard Pearson, the leading RSI specialist in the
UK.

Several other physiotherapists are aware of AMT, including the ones
treating me; however, Wendy's explanation is the best that I have
heard in over 6 months of trying to find out about this.

She is writing a book on RSI, incorporating info on AMT; I will post
details to this list when it is available.

The following is based on notes of a talk given by Wendy, and may
well contain errors introduced by me, especially where I have added
material for clarity; I have also added some of my own opinions on
how to manage your own RSI, though these have mostly been validated
at a group of RSI sufferers, so they are not purely personal ideas.

The big weakness of this AMT info is that it does not explain how and
where other RSI disorders such as CTS and tenosynovitis fit in.  I
suspect all types of disorders can be mixed in, including AMT.

NOTE   I am not medically qualified, and everything in here should
       be checked with therapists who understand RSI and are aware of AMT.
       If they haven't heard of AMT, or deny it exists, consider a
       second opinion.

----------------

RSI (Repetitive Strain Injury) tends to progress through a number of stages:

    1. Neck/shoulder stiffness and possibly pain

    2. Hand/wrist pain

    3. Lower and upper arm pain

As the condition advances, arms and hands may become weaker and
other symptoms may appear.  However, there is very little fixed
pattern to RSI symptoms, so every case will tend to be different
in detail.

RSI is not a very good acronym.  The main problems are not caused
by Repetition, though this can 'kick you over the edge' into a flare-up.
Nor is Injury itself always a big factor, though some people may indeed
have tenosynovitis, nerve damage due to carpal tunnel syndrome (CTS), and
so on.

The three main factors in RSI, according to the AMT theory, are:

    1. Poor, static posture

       This means you are sitting in the same position all day, with arms
       flexed (i.e. bent) for typing, writing, reading, or meeting people.
       Without enough breaks, and with a poor posture that increases the static
       loading on a number of muscles, the muscles then become shorter and
       denser, impeding blood circulation, especially in the arms, neck
       and shoulders.

       This is usually first signalled as back pain, shoulder pain or
       neck ache, as much as FOUR OR FIVE YEARS before hand pain
       is felt.  Think back to whether you have ever had stiff shoulders or
       an aching neck, especially after a lot of fixed-posture work.

       This 'adverse mechanical tension' leads to nerves becoming 'tethered'
       within groups of locked-up muscles, usually in the shoulders and
       upper back.  This is rather like a hosepipe getting snagged in
       pebbles/rocks on the ground [this may require translation for US
       English!]

       Eventually, 'neural tension' develops -- this is purely physical
       and has nothing to do with being tense psychologically.  The nerves
       simply contract, usually those which are never extended (e.g. the ones
       running along the inside of the arms).

       In this state, raising the shoulders (common while driving) or using
       the arms in a bent position for some time will cause pain.  This
       pain is REFERRED PAIN -- caused by nerve tension all along the
       arm, and by tethering in the upper back, but felt as pains
       in the fingers, hand, wrist, forearm or upper arm.  This is
       very hard to believe until you find that neural stretches make
       what seemed to be a damaged part of your arm get better (see below)!

       Electronic keyboard work is worse than mechanical typing partly
       because fewer breaks are taken and the posture is more rigid.
       Mechanical typewriting is worse than writing, for similar reasons.

       A quick exercise/test for nerve contraction: drop your arm straight
       down by your side, palm forward, elbow fully extended (locked), and
       then drop your shoulder (use your other hand to help if you do
       this a lot).  Then bend your wrist back until you feel a slight
       'pull' in your middle and index fingers -- this is the nerve being
       stretched back.  If you are able to bend your wrist 90 degrees back
       in this position, that's good!  Don't use your other arm except to
       push down the shoulder.

       There are many variations on this neural stretch, which are technically
       called 'brachial plexus' stretches.  This stretch is active
       since it involves the arm's own muscles in the stretch; if you have
       RSI you may find passive stretches, in which you lean against a surface,
       are less demanding.  Don't push any neural stretches too far,
       even if they don't really hurt -- just go a bit beyond what is
       easy, and do the stretches frequently, for 10 to 15 secs each time.

    2. Stress

       Stress multiplies the problem of static posture manyfold, because
       the muscles automatically tighten up when you are stressed, making
       your posture even more immobile and further tethering nerves in the
       upper back.

       This is the source of the common misconception that RSI is psychological
       in origin (for example, British Telecom's Chief Medical Officer
       has stated that RSI is a non-existent disorder (sic), thereby implying
       that all sufferers are malingers (sic)).

       So: you feel tense, stressed, under imposed or self-imposed
       deadline/productivity pressure, harassed by software or
       hardware that breaks, hassled by problems at work or
       home, and all this simply makes your RSI worse.  You go
       to your doctor, who notes your stressed state but often
       cannot find anything 'physically wrong' with you
       (i.e. no obvious arm/hand damage), leading to his/her
       feeling that it is psychological.

       Even more insidious: if one person in a group gets RSI, the others
       immediately take note of their own pains and worry much more
       (= more stress), causing any existing AMT problems to be magnified.
       This is probably one factor in the very rapid spread of RSI within
       workgroups, which has caused some to mis-diagnose it as 'mass hysteria'.

    3. Repetitive motion

       This is in fact the smallest risk factor.  However, it does eventually
       cause relatively minor injuries, in the same way you get tennis elbow
       from overplaying tennis.  These injuries are greatly exacerbated
       by poor, static posture and by stress; they would often heal up
       but are prevented from doing so.  They are localised and cause localised
       pain, unlike static posture and stress.

It takes years to get to the point of shoulder, hand then arm pain
and can therefore take a long time to cure (though the cure
time seems to be a lot less than the time to get RSI, thankfully).

The following treatment by a physiotherapist (= physical therapist) skilled in
AMT seems to be fairly standard:

    1. Testing for 'adverse mechanical tension' -- this involves stretching
       the arms and turning the neck to see where contraction/stiffness prevents
       further motion.

    2. Mobilising the cervical and thoracic spine (i.e. neck and upper back),
       which unblocks locked-up muscles and helps nerves to extend.  Very
       little arm treatment initially, maybe 2 mins in a 30 min session.

    3. Stretching nerves, etc to reduce adverse mechanical tension -- this is
       demonstrated for 2 mins or so, then practiced by you continually
       throughout the day, whenever pain/aches are felt, and perhaps also
       in the evening for tens of minutes at a time.

You will probably find that the RSI gets worse for a short period
after treatment, but this should be less than 2 days, and it should
then be better.

You may have trouble finding a competent AMT physiotherapist: they
are really quite rare, and the only hints are to find a physio who
treats a lot of RSI patients and uses this type of treatment.  In
the UK, private physiotherapists are able to specialise, unlike
NHS ones; also, Australian physios have brought a major base of
AMT treatment skills into the country.

Controversial advice from Wendy: don't get a diagnosis!  The theory
is that simply labelling yourself will not help you, the real issue
is getting treated.  I have to say I disagree with this, you need
to see a rheumatologist who specialises in RSI (NOT an orthopaedic
surgeon, they are understandably biased towards surgery!) and
check that you do not have some non-RSI disorder and to discover
if you have advanced CTS, necessitating surgery.

There are a huge number of things that you can do to help cure yourself,
which help both psychologically, in that they help you control the pain
and the condition, and physically, by helping to reverse the effects of RSI.
Here is a list, additions welcome:

     Avoiding or mitigating poor, static posture

	 - almost any sport (but avoid swimming with breast stroke unless
	    you use goggles and put your head underwater -- otherwise
	    your shoulders will get worse)

	 - frequent breaks, with stretching, walking around, chatting,
	   standing up to make phone calls, etc.  Various software
	   tools exist to help you take breaks and exercise, contact
	   me for a list.  The Japanese approach of everyone
	   doing exercises in unison may not be right for other
	   cultures but it has a lot to recommend it.

	 - mixing typing with phone calls, talking to colleagues,
	   writing (but be careful of your posture in writing)

	 - all the normal advice on ergonomics -- particularly,
	   try to get your shoulders DOWN, not hunched up (probably
	   need to raise your chair and maybe get a foot rest).

	 - Alexander technique: this aims to correct unconsciously
	   poor postures at all times

	 - Feldenkrais method: this tries to correct poor body movement
	   habits through movement exercises

	 - alternative keyboards that allow typing with palms facing
	   left-right not downwards (reduces strain on forearms)

	 - keep moving!  Try to avoid just sitting in front of
	   the TV or reading a book for long periods of time -- get
	   up, take a walk, go dancing, anything that gets
	   your upper back/shoulders moving without using your
	   arms too much.  The mental image of a monkey, continually
	   moving about and fidgeting, is not a bad one!

	 - when driving, try to shift arm position frequently,
	   and keep your shoulders down.  Adjust the steering
	   wheel down as far as possible, and drive one-handed,
	   switching hands.  Also try cushions to raise you
	   up a bit.

	 - when writing, try to adopt a similar posture to when
	   typing, i.e. do not lean forward and down as far as possible.
	   Try using a lower seat or higher work surface.  Inclined
	   work surfaces cost very little in some cases and simply
	   rest on the desk (will also help back pain).

	 - massage of various types, including shiatsu

	The best bet is to combine a deep-seated change of posture,
	which will require training, with increased motion to keep
	your upper back mobile.

	Some controversial advice:

	   - consider not using arm rests (whether on chair or designed
	     for RSI sufferers): these risk pushing the shoulder up,
	     and enforce a static posture, but may be OK otherwise.

	   - consider not using wrist rests, for similar reasons.  If you
	     do, use a VERY well padded rest, and never the table, and
	     never ever the edge of the table.

     Regular (every day, one or more times) stress reduction
	 - deep breathing exercises (sit up, or lie down on floor
	    with slim pillow, but not on bed)
	 - meditation
	 - yoga
	 - listening to heart beat
	 - tai chi
	 - biofeedback

	 - massage of various types, including shiatsu

	 Quote from Wendy: 'you should become an expert on relaxation'

	 Books: Full Catastrophe Living (New York, Dell Publ),
			ISBN 0-385-30312-2
		Stress and How to Manage it (UK)

	 There are various other ones, I have an alternative therapy
	 guide that mentions a lot of them -- contact me for details.

      Avoiding repetitive motion
	 - slowing down your typing
	 - try a Dvorak or other alternative keyboard

More controversial advice:

    - only use heat, cold, ultrasound or laser treatment as a temporary
      palliative, and use relaxation pain control in preference.  The
      former techniques will not cure you, only help you for a while.

    - consider not getting CTS surgery: AMT treatment can help people
      with CTS, though you have to think VERY carefully about this,
      since if CTS is advanced you have only a limited time to
      get surgery before nerve and ultimately nerve sheath die-back
      occurs, which is note reversible.  Here you really need expert
      advice from someone who can advise of the relative merits
      of each form of treatment, in an unbiased way.

Getting more sleep can be important if you are already not sleeping
enough; however, circulation slows and fluid retention increases
during sleep, which can make the RSI (and particularly CTS) worse when
you wake up.  Generally, sleep helps because you are not stressed or
in a static posture, but meditation etc gives much deeper relaxation.

Complete rest from ALL hand/arm activity is NOT recommended: this simply
makes the static posture problem worse.  If your arms are painful,
try walking with your arms swinging gently.

RSI is usually completely reversible providing you don't let it get
too far: e.g. very severe pain at all times may not be completely reversible,
though it can probably be helped.  Basically, even if you are in a bad way,
something can probably be done, so don't despair!

    If you have shoulder or neck pain, you are at some risk -- the next stage
    is likely to be hand pain unless you apply the above.

    If you have pain in your hands or arms, YOU MUST GET TREATMENT ASAP
    or resign yourself to progressively worse bouts of RSI.  The pain normally
    goes away for a few days, weeks or even months, depending on the above
    factors, but this does NOT mean you are cured - it will be worse
    next time unless treated.  The treatment will simply be some physiotherapy,
    with exercises to do during and outside work - it won't mean time off
    work.

    If your hand/arm pain persists outside work and does not settle overnight,
    your condition is further advanced, but the advice is as above.

You need to take time off from typing or whatever activities cause
you pain, NO MATTER WHAT.  Do not delay this, you are simply making matters
worse -- the sooner you take time off these activities, the less time you
need off and the quicker you recover.

If you want more info, contact me or wait for the book from Wendy.  Any
other sources of info would be interesting to hear about: I believe
significant work on AMT was done by David Butler, an Australian researcher.

I hope this was useful and interesting: all comments are welcome.

Richard

=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=
  Richard Donkin                          Hoskyns Group plc
  Internet mail:                          Tel: +44 71 814 5708 (direct)
    Work:  richardd@hoskyns.co.uk              +44 71 251 2128 (switchboard)
    CIX:   richardd@cix.compulink.co.uk   Fax: +44 71 251 2853