NonSurgical Treatment Options for Upper Extremity Overuse Injuries

Richard N. Norris, M.D. December 1994 - August 1995

This multi-part article will discuss the nonsurgical treatment options of (relative) rest, medications, injections, thermotherapy, electrical stimulation, massage, therapeutic exercise, returning to work after injury ("work hardening"), modification of posture and technique, "feedback" techniques, orthotics, splints, and assistive devices for daily activities.

Part 1

Reprinted From The RSI Network - Issue 21 - Dec'94

First, a note: Repetitive motion disorders can usually be treated nonoperatively with success, especially in their early stages. However, it should be kept in mind that nonsurgical treatment isn't always the conservative path, and there are many conditions that respond quickly and reliably to surgical procedures. In situations of prolonged pain and disability, nonsurgical procedures should not be pursued indefinitely when surgery would correct the situation and allow the patient a rapid return to work or play.

(Relative) rest: Perhaps the most important treatment of all is rest. We all know how difficult it is for professionals to take time off to rest, so we must borrow the concept of "relative rest" from sports medicine. Depending on the severity of the injury, this may mean cutting back, rather than completely stopping, work or (for musicians) performances. Office workers may need to cut down on work hours or space out the typing or writing over the course of the day. For musicians, it may be possible to modify or change the repertoire, such as avoiding piano pieces with large chord spans, broken or serial octaves, or triple forte playing. Relative rest really means avoiding pain-producing activities.

Medications: The most commonly used medications are nonsteroidal anti-inflammatory agents. (Caution must be used in patients with a history of ulcers, bleeding disorders, or hypertension.) They should be taken with meals. In general, anti-inflammatory medications tend to be more useful in acute than in chronic situations, and should probably be used not more than 3 or 4 weeks at a time. They should rarely be used as the sole treatment modality, but may be helpful in conjunction with other modalities and treatment strategies. There is evidence that topically applied salicylate cream (trolamine salicylate) may be effective for localized inflammation. In addition, low doses of antidepressant medication are often helpful as part of the treatment of myofascial pain. Narcotic medications, sedatives, or "muscle relaxants" should be avoided.

Injections: Dry needling or injection with anesthetic alone is routinely used in treating myofascial trigger points. Injections performed with a solution of corticosteroid and anesthetic are commonly used as part of the treatment regimen for de Quervain's disease, sub-deltoid bursitis, trigger finger, and epicondylitis. For median nerve entrapment at the wrist (CTS), it's best to avoid the colloidal steroid preparations and use only the soluble steroids, as colloid solution has been found lying on the median nerve at surgery, possibly causing mechanical irritation. Injection is generally contraindicated for patients with any weakness or thenar atrophy or advanced sensory loss.

Patients with minimal or intermittent symptoms of CTS tend to have the highest success rate. D. P. Green found steroid injections to give good to complete relief of CTS in 81% of patients. In most patients the symptoms recurred from 2 to 4 months after injection. He found a positive response to an injection to be an excellent predictor of a successful surgical procedure. The injection is performed by insertion of a 25-gauge needle proximal to the wrist crease and ulnar to the palmaris longus tendon. This avoids the median nerve and the transverse carpal ligament. The patient can be asked to gently flex the digits a few degrees; if the needle is in contact with the flexor tendons, there will be slight movement of the syringe, assuring proper position before injection. To avoid injecting into a tendon, the injection must not be forced against pressure. If injected proximal to transverse carpal ligament through the investing fascia of the forearm, the solution will easily flow into the tunnel and the area of tenosynovitis.

Part 2

Reprinted From The RSI Network - Issue 21 - Dec'94

Thermotherapy: Thermotherapy can take the form of heat or cold. Heat is commonly applied as either a hot pack, which doesn't have much depth penetration, or ultrasound, which has much deeper penetration. Ultrasound can be pulsed or continuous; pulsing helps prevent excessive heat buildup and should be used in bony areas such as hands and wrists. An ultrasound unit with a very small head works better for bony areas. In treating areas of nerve compression, ultrasound should be used only in very low doses (in the range of 0.5 watts/cm2). A normal dose (1.5 to 2.0 watts/cm2) actually has been shown to be deleterious to nerve healing.

Fluidotherapy is a type of thermotherapy using heated, pulverized organic material such as walnut shells or grain husks. Advantages include the ability to attain higher specific heat than with other methods of application, and the opportunity for the therapist to put his or her hands into the fluidotherapy bath to perform joint mobilization or soft-tissue massage concurrently. Although the heat of paraffin baths doesn't penetrate deeply within the tissue, these baths are very good for dry skin and for relaxing contracted areas. If inflammation is present, cold serves as a vasoconstrictor to prevent or reduce swelling. Ice may be applied for 15-20 minutes every hour or two as needed. When applying cold over sensitive, bony areas, it's best to use a gel pack, which remains soft even at freezing temperatures.

Electrical stimulation: The use of electrical stimulation is often beneficial when there is edema or swelling, as the current can help to polarize and drive interstitial edema back into the vascular system. This treatment should be combined with compression and elevation. Electrical stimulation can be used to induce gentle, rhythmic muscle contractions in sore areas, helping to relieve discomfort by removing interstitial edema and increasing blood flow to the muscle. Electrical stimulation can also be used with active muscle contraction to strengthen weak or atrophied muscles. Caution must be used with patients who have pacemakers and those with very sensitive skin, which can be irritated by the electrodes.

Massage: Massage is useful in stimulating blood flow, reducing edema, and breaking up localized areas of muscle spasm or trigger points. It's also helpful for general relaxation and stress reduction.

Therapeutic exercise: Physical exercise plays a vital role in keeping workers and performers fit and healthy. Sitting at a desk or making music, while not athletic in the strict sense of the word, definitely has its physical demands. Therapeutic exercise is useful in both preventing and treating specific ailments. Often, after a period of injury, the muscles in the hand and forearm become weak from disuse or nerve compression. Therapeutic exercise, along with a gradual return to working or playing, is necessary to restore muscle strength and endurance. Working on proximal strength, especially scapular stabilization, is greatly beneficial. Strengthening the wrist and finger extensors, a common area for pain and dysfunction, may be preventative as well as therapeutic. Hand exercises must be undertaken with caution and supervision because of the risk of overdoing the exercises and thereby worsening the condition. One of the chief offenders in causing further injury is therapy putty, which tends to be rather stiff, especially when cold. There are several different colors of putty available in varying degrees of stiffness and resistance. Putty must be used in a graded fashion and prewarmed. Rubber bands and manual resistance may also be used. A well-balanced therapeutic exercise program should address strength, endurance, flexibility, and gracefulness.

Read parts 3 and 4 about NonSurgical Treatment Options for Upper Extremity Overuse Injuries

Visual Ergonomics in the Workplace

Reprinted from The RSI Network - Issue 38 - May'99

Dr. Jeffrey R. Anshel, BS, OD

Corporate Vision Consulting

Encinitas, California

1-800-383-1202

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http://www.cvconsulting.com

Vision is our most precious sense. Our eyes are in constant use every waking minute of every day. The way we use our eyes can determine how well we work throughout our lifetime. Over 80% of our learning is mediated through our eyes, indicating the important role our vision plays in our daily activities. Vision disturbance is a silent enemy that only appears after a long period of continued stress.

In the past decade, computers have taken industry and business by storm. It is estimated that over 70 million Americans now use computers regularly. We are increasingly becoming an information society, and the price we are paying is our eyesight.

The human eye has been essentially unchanged for over 40,000 years in our evolution. However, in the last 100 years or so we have been gradually altering our viewing tasks from predominantly distance to near work. Today we spend a disproportionate amount of time involved in close work. To adapt to this change, our eyes have become increasingly near-sighted. Researchers have confirmed this shift toward increased near-sightedness in our society. This is much more prominent in the population of computer users. Let's look at the different factors that affect our eyes while using a computer.

The Terminal

Using a computer differs significantly from traditional reading in many ways. There is a difference in looking at a white piece of paper with black letters that reflects light versus looking at a (usually) black screen with various colored letters that is self-illuminated. The additional light coming from the screen dictates that less surrounding light is necessary. The light emanates from the screen by a process that continually refreshes a phosphor coating so the image doesn't fade. This refreshing of the coating must be accomplished at a rate of more than 60 times per second. If it occurs at a slower rate, the user will experience the "flicker" that is similar to that of an old fluorescent light. People experience this flicker differently, and screens have different flicker rates. This can be a very distracting and stressful experience for the terminal user. One can reduce flicker by dimming the brightness of the screen. However, that can lead to other potential problems, which will be discussed later.

Eye Position

There is a considerable difference in the normal eye position when looking at the terminal as compared to reading. Conventional reading is normally done while looking at a 14-16" working distance, with the reading material held in a lowered (about 40 degrees) position. The straight-ahead position used by many computer users is unnatural. The muscles must fight one another to achieve a balance and maintain the image correctly in the eyes. This can lead to fatigue, eyestrain, or headaches. Ideally, the center of the screen should be 7-10 inches below your horizontal line of sight.

Glare

Glare is any extraneous scattering of light. There are many sources of glare in most office situations: improperly positioned lamps, fluorescent lights, outdoor light, highly reflective surfaces, or any illuminated object. The glass surface a computer terminal can be highly reflective. While the eyes are in the straight-ahead position they are more susceptible to outside sources of light, especially those coming from the ceiling.

There are many ways to reduce glare. The first way should be with an anti-glare screen for the monitor. The most common screens are mesh or glass and each has its own advantages. Glass screens are generally better but may lead to further reflections if they don’t have anti-reflective coating. Although they are more bothersome to keep clean and are more expensive, they do an excellent job of reducing glare.

Secondly, reduce glare by positioning the screen properly. While the screen is off, angle it so that you can see no reflections of any lights on the front surface of the screen.

Another solution may be a bit more difficult to control. Traditional lens panels on fluorescent lights are often a significant source of glare. These units can be retrofitted with louvers that direct the light straight downward instead of allowing scattering. This will create a dimmer working environment but will be much more soothing on the eyes. Research has found that most offices are much too bright for terminal work. The surrounding illumination should be only three times as bright as the screen you are using.

If glasses are worn while using a computer, you'll probably benefit from a very slight pink or rose colored tint in the lens. This is a barely noticeable tint but will help to offset the scattering of light around the office.

Computer Glasses

If you wear glasses regularly, the prescription is usually designed to help you see better at a distance (while driving, for example). However, the power required for clear distant vision may be different from what will make your eyes most comfortable at 20-25 inches. How your eyes focus and work together will determine the proper prescription for glasses at the close distance.

If you haven't worn glasses at all before, get your eyes examined by your eye-care professional. Be sure to tell him or her that you work on a computer terminal and give them as much information about it as possible, i.e., working distance, lighting conditions, amount of time spent at the terminal, symptoms you experience, etc. Very often special computer glasses will be prescribed simply to ease the effect of long hours looking at the screen.

If you are over the age of 40, you probably have (or soon will) experienced difficulty changing focus to near objects. This is the usual decrease in the eyes' ability to focus as we age. Glasses used for reading and computer work can let you function normally again. If you already wear glasses for distance and experience difficulty focusing, then bifocals may be in your future. As the traditional bifocal is not well suited for computer vision, an alternate choice may be necessary. Some new lenses have no lines and provide for a full range of distance, intermediate, and near vision, so be sure to ask about as many alternatives as possible.

If you have contact lenses, you may be experiencing dryness and discomfort while working on your terminal. The first problem can often be attributed to the environment. In areas that have computer hardware, air filters are often used to dry the air to make the conditions optimal for the computer. Less moisture in the air causes your eye lenses to dry. In addition, the cooling fans of the units themselves draw more dust into the area, creating more problems. There is also a tendency to blink less when doing intense close work. Lubricating drops recommended by your doctor will help relieve the symptoms of dryness.

Vision Therapy

Sometimes it is not enough to take precautions and/or use glasses. If your visual system is not able to make necessary adjustments to work effectively, you probably could benefit from vision therapy.

Vision therapy is a program optometrists offer to teach people how to use their eyes properly and with less effort. It is an integrated program of techniques and procedures that help the person improve all aspects of vision, including general coordination, balance, hand-eye coordination, eye movements, eye teaming, and focusing efficiency. It is done on patients of all ages for any number of different problems. Your local Optometric Society can give you names of doctors in your area who specialize in vision therapy.

Computer Vision Testing

A recently introduced software program has been shown to be effective in conducting a vision screening test on the computer and determining VDT-related visual stress. The Eye-Computer Ergonomic Evaluation (Eye-CEE) System for VDT Users® consists of an on-line questionnaire as well as vision tests that can determine if your symptoms are related to your vision or to your environment. The program produces reports that can be taken to your doctor to help do a more effective examination of your vision.

Eye Self-Care

There are many things you can do for yourself to reduce computer-related eyestrain. I've narrowed these down to a "3 B's" approach: Blink, Breathe, and Break.

Blink: Blinking is an automatic function. It also happens to be the fastest reflex in the body! We usually blink at a rate of about 12-15 times a minute in normal situations. (Unfortunately, we have not yet figured out what a normal situation is.) We blink more often when we are excited, stimulated, anxious, talking, and doing general physical activity. We blink much less frequently while quiet, which includes reading, thinking, and concentrating on a particular task. This staring can strain the eyes. Blinking allows our eyes to rest for a short time, and also cleans and re-wets the eye surface to maintain clear vision. Because blinking is so automatic, it might take some concentration at first to make sure you maintain a normal blink rate while working at a terminal. Just being aware of this concern will allow you to blink more normally.

Breathe: Our breath is our life. Our entire body is governed by the exchange of oxygen and carbon dioxide from the breathing process. When we reach a stressful situation in our activities, we tend to hold our breath to "break through" the situation because the breath can control our muscle activity. If we hold our breath, we may tighten muscles in places where we are not even aware. Correct breathing—even and steady—can relax the eye muscles as well.

Breaks: With the intense concentration we apply to computer work it is not surprising that we need more breaks. Our eyes were not designed to be used at such a close distance for a long period of time. I've devised a plan of breaks that will allow you to do the maximum amount of work and still allow you to relax your eyes. These are called: Micro-, Mini- and Maxi-Breaks.

Micro-Break: This break is only for about 10 seconds and should be taken about every 10 minutes. Look far away from your terminal (at least 20 feet) and breathe and blink easily. Keep your eyes moving while looking at different distant objects. This should not interfere with your work or your concentration.

Mini-Break: Take this break about every hour; it should last about five minutes. Stand up and stretch. I often recommend doing eye exercises during this break so the eyes can flex and be used in different seeing situations. Ask your eye doctor which exercises he or she would recommend.

Maxi-Break: This could be a "coffee" break or lunch. The maxi-break is a "get up and move" type of break that will allow your blood to start flowing again and get you more energized. This kind of break should be taken every few hours.

There is no one solution to all types of problems encountered with computer use. However, education and common sense can help to reduce your potential risk. Our productivity is supposed to be increased with computer use, but this should not occur at the expense of our eyesight. We need to co-exist with computers and use them to their fullest potential. The answer to many of these problems may be right before your eyes!

About the Author

Dr. Jeffrey Anshel graduated from the Illinois College of Optometry and served as a lieutenant in the U.S. Navy in San Diego, where he established the Navy's first vision therapy center. In 1990, he published Healthy Eyes, Better Vision, a layman’s reference book containing practical advice regarding vision care. Taylor & Francis has just published his second book, Visual Ergonomics in the Workplace. Dr. Anshel is currently the principal of Corporate Vision Consulting, where he addresses issues related to visual demands on computer users. He also maintains a private practice in Carlsbad, California.

Workstations Integrated with Conveyor Systems

Joy M. Ebben, PhD, CPE, CHFEP, DABPS

March 5, 1999

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I am often given the opportunity to tour manual assembly environments, either as a guest or as part of an ergonomic workplace evaluation. One of the common problem areas I have observed is how workstations are used in conjunction with conveyor systems. Often conveyor/workstation systems require the user to work in awkward, non-neutral postures and the conveyors create contact force on arms, wrists, and legs.

Advancements in understanding ergonomic requirements in workstation design have provided significantly improved conveyor/workstation systems for seated operations. However, providing proper working height for standing operations is still a cost challenging proposition.

Why Use Conveyors?

The first question to ask is do you want a conveyor as part of your workstation configuration. In addition to creating difficult ergonomic problems for the workstation configuration, conveyors are often costly but yet inflexible. For example, you can not usually change a straight-line conveyor into a U shaped conveyor. So, you want to be sure that a workstation/conveyor system is really the right approach for your manufacturing environment.

Conveyors are used to move product between people or between people and automated equipment. The primary application for using a conveyor system to move product between people is for performing in-line assembly when each person completes a small number of tasks of short duration and a number of people are required to complete the assembly. Alternatively, the employee completes a batch of products and then uses the conveyor to transport the batch to the next station. Used in this fashion, material handling time and exerted force is reduced for employees.

Sometimes it is better for one person to complete all the assembly tasks. This provides "job enlargement" for the employee which could result in increased job satisfaction and possibly a reduction in the risk of musculoskeletal disorders. Having one person complete all steps is a useful concept to consider. But, it is most useful when all the required tools and piece-part components can be properly incorporated into a single workstation, when another person does not need to check the quality of each manual operation, and when the training approach supports everyone learning how to complete all tasks.

If someone is completing all tasks, then the conveyor can be used to move the item from a single workstation to an automated operation. However, if the next station is a manual station it may be better to move the assembled unit using some other type of material handling equipment, like adjustable customized carts. This is particularly true if the preferred design for the test station allows the employee to sit or stand. If it is determined that part of the task should be performed standing, the conveyor system becomes much more complicated in order to accommodate different working heights for standing individuals.

So, conveyors are not always the best solution for material handling when all factors are taken into consideration. But, if you have determined that the best approach to performing a task is seated, in-line progressive assembly, a conveyor may be a very appropriate part of your workstation configuration.

Layout

Two different workstation/conveyor layouts are typical -- the workstation positioned perpendicular or parallel with the conveyor.

(Perpendicular)

(Parallel)

The perpendicular orientation usually requires the employee to use awkward postures in order to move items on and off the conveyor. The extent of this problem depends upon the size of the workstation, where the person is seated at the workstation, and the size, weight, and shape of the item to be moved. Another potential shortcoming of a perpendicular layout is the limited viewability of other workers on the line; the person can easily see operations only in the direction they are facing.

One advantage of the perpendicular arrangement is that the workstation can have a much larger surface size without increasing reach distances to the conveyor. This is useful if there are large pieces of equipment or components that require worksurface space. The surface can be larger without negatively impacting accessing items on the conveyor system.

Parallel layouts, if designed properly, can reduce awkward postures and facilitate cooperative work because of the improved line-of-sight. A good design for seated operations in a parallel configuration addresses the following:

Minimize reach distances to the conveyor, depending upon reach frequencies, item weight, item size, and conveyor width. This requires a narrow worksurface but one that is sufficiently large to provide space for all tools and the tasks to be performed. Remember the reach distances include horizontal as well as vertical reach components.

Provide sufficient knee, leg, and toe clearance underneath the worksurface and conveyor. This may require customized conveyors including minimizing the thickness of the conveyor system. The lower the profile, the better.

Accommodate the working height for different employees through the use of adjustable chairs and footrests. The appropriate adjustment range for the chair and footrest needs to be calculated based on working height and employee anthropometrics. The workstation should be set appropriately for the tallest employee and then accommodate make for shorter employees.

Facilitate material handling off of the conveyor for heavier items using ball transfer systems, rollers, or other assisting devices.

Minimize contact stress by providing rolled-font edges on the worksurfaces, sufficient leg clearance, and eliminate the need to rest body parts on the metal components of the conveyor system.

Providing parts cups can be a problem with parallel configurations because of limited space and required access to the conveyor and required clearance above the conveyor. Possible approaches include:

• Adjustable swing arms and parts rails
• Gravity feed systems
• Inserted parts-cups into worksurface
• Mobile parts cup carts/stations
• Redistribute tasks

Sit/stand Operations

Workstations used sitting/standing or simply standing that are associated with a conveyor systems should provide some method of adjusting the workstation's height. This adjustment allows employees to adjust the height of the object they are working on to be appropriate for their body dimensions and the type of task to be performed. Systems are available (albeit expensive) that provide height adjustable workstations used in conjunction with a conveyor. Using control systems and conveyor "bridges" connected to the workstation surfaces, an individual employee can properly adjust the height of their workstations and still be connected to the adjustable conveyor ramp that would take the product to the fixed height main conveyor line. This sophisticated approach may be the design of choice when using sitting/standing or standing workstations and when a conveyor transportation system is the preferred material handling approach.

Perpendicular Arrangement with Conveyor "Bridge"

Work Pace

Another concern with conveyor systems is the potential for creating unacceptable work loads. Workload is a recognized risk factor for occupational stress and injuries. Two main methods for controlling the pace of work along conveyors are:

1. Machine paced: - speed of the operation and the work output is controlled by a source other than the operator and
2. Self-paced: - allows the operator to work at a self-determined speed without the pressure of maintaining the rate of the machine

Conveyor systems can be designed to be machine paced, self-paced, or some combination of the two.

Self-paced operations are superior because they allow individuals to work at a rate that is safe and effective for themselves, not at a pace that is externally determined. The issue of pace works in both directions -- underworked and overworked. An underworked person on a machine-paced conveyor becomes bored, may use risky posture like extended reach to acquire an item before the conveyor presents it, or becomes distracted when waiting for the next task reducing productivity or quality.

Probably more of concern is the person that is paced by the machine to work faster than they are comfortable. Perceptions of heavy workload and associated stress and strain occur in response to fast-paced, short-cycle, and highly demanding tasks that do not provide opportunities for variety, interruption of the work cycle, or rests breaks - a close description of many workstation/conveyor operations. As workload increases there is more work pressure and heightened performance demands, forcing employees to remain longer at the activities. Increased psychological stress and repetition can encourage risky shortcuts which can increase the risk of WMSDs.

A conveyor system should be designed to allow for self-paced operations. This can be accomplished in a number of ways including providing individual holding areas, multiple person performing the same task, or returning items that are "passed-through" incomplete.

Conclusion

In conclusion, if you are considering using workstation with conveyor systems you have a number of ergonomic questions to address to help minimize exposing employees to musculoskeletal risk factors of awkward postures and contact stress. In addition, but not addressed here, are the issues of conveyor noise levels, conveyor control method and devices, and layout flexibility. Find a workstation manufacturer that has the expertise to help guide you through these ergonomic design issues to help ensure a successful implementation.

RSI And Applied Motor Control

Reprinted from The RSI Network - Issue 33 - Nov/Dec'98 Howard Nemerov, CMT Corte Madera, California (415) 459-4206 This e-mail address is being protected from spambots. You need JavaScript enabled to view it

A number of clients who have been treated with Applied Motor Control have said things like: "I had seen conventional physical therapists for three years, trying to resolve pain and tingling in my hands, to no avail. When I started treatment with Howard, the problem went away, and has never returned." (SM, Kentfield, CA) "Howard's work is an integral component of manual therapy. It allows the client to quickly re-establish neural pathways to relax compensating muscles and regain coordinated control of both spinal and extremity motion. My work with Howard has considerably eased my own long-standing neck and arm pain." (Brian Beaudoin, PT, OCS)

These quotes reflect the fact that while other forms of treatment may help, they do not address the underlying neurological problems in the muscle system. These problems arise from repetitive stress, and do not get resolved until they are treated in the detailed, thorough, and orderly way that AMC addresses them.

In this article I will describe some basic concepts of Applied Motor Control, and how it can enhance and hasten your rehabilitation.

What Is Motor Coordination?

For every movement pattern, a unique sequence of muscle actions occurs in order for the movement to be smooth and easy. To take a sip from a cup of tea, you must reach out, grab the handle, lift the cup, and bring it to your lips. If you did these actions out of sequence, you would not achieve the desired action of sipping tea. If you tipped the cup before you got it to your mouth, you might have a surprise! All of these arm and hand muscles must perform their individual jobs, yet within the team context involving the other muscles.

The part of the brain that governs this process of motor coordination is called the Motor Control Center (MCC). The MCC learns and remembers movement. It decides which muscles to use and in what order. Sipping tea from a cup involves dozens of muscles, but you never think about that because the process happens so easily. This ease is a sign that a motor function is efficient. The proper muscles are activating at the proper times, and the desired outcome, drinking from the cup, is accomplished.

How RSI Leads to Dysfunctional Motor Coordination

Smooth, efficient movement is the ideal, but not always the reality. Injuries such as whiplash, sports injuries, and RSI all can cause muscles to overload and "short out," much like an electrical circuit that is drawing too much current. One can easily see how a large impact in an automobile accident could cause such a neurological overload. Heavy strains like these cause dramatic, intense stresses to the muscles, causing them to "short out" in less than a second.

With RSI, small stresses over a much longer period add up to the same type of overload. You can load the muscles with 100% of the force needed to weaken them all at once, or you can give them slight overloads of 1% of that force over 100 days. Either way, you end up with 100%.

Keyboard typing for long periods of time is one way to build up strain gradually. It may seem like a pretty easy activity, but two factors cause it to create RSI.

First of all, the palms-facing-down position is not neutral, and shortens the muscles and tendons in the arms, even if your wrists are straight.

Secondly, when we do any kind of activity without balancing it with rest, stretching, and therapeutic exercise to refresh the muscles, they eventually build up to that critical stress we discussed earlier. When this happens, they begin to hurt, which is the muscle’s way of saying "I’m tired." After a long day of typing, if you notice soreness in your shoulders, arms, or hands, you are experiencing this problem.

Of course, we have deadlines, competition, and the need to perform well at our jobs to avoid being replaced, so we override these signals. After all, what’s a little soreness? It may actually be a badge of courage or a sign that we are tough enough to hang with the best, right? But, as the old margarine commercial went: you can’t fool Mother Nature. If you continually stress your arms and hands, they will eventually break down. Some bodies are more resilient than others. Younger bodies generally recover faster than older bodies. But eventually, something gives.

What happens at this point is extremely interesting. Many times, you don’t even register that your arm functions are breaking down, because after the Motor Control Center sees that you are not going to stop to rest and recuperate your strained muscles, it becomes a trooper and figures out a way to keep going as best as it can. As fatigued muscles weaken and switch off, the MCC looks around for other muscles that it may recruit and substitute. It creates a backup coordination pattern that, while not as efficient as the original pattern, mimics the original enough to allow you to keep at your work. This is also called a compensation pattern.

Compensation patterns put additional stress on the muscles that are recruited, because now they must perform both their original function as well as the compensation pattern. It is very similar to what happens when you are part of a project team. At first, everybody has their assigned responsibilities. If everybody carried these out according to the original plan, the project would be completed with a minimum of stress to each team member. If two people get very sick or quit during the project, the remaining team members often complete the project, forcing them to perform additional duties as well as their original ones. By the end of the project, they are burnt out and cranky. Muscles that have been involved in compensation patterns also get tight and sore, their version of being burnt out and cranky.

Let’s look at the specific activity of typing. You bend your elbows to place your hands on the keyboard. On most of the keyboards in the workplace, unless you are fortunate or rich enough to purchase a top-of-the-line ergonomic keyboard, your wrists are bent back slightly, and your fingers are raised over the keys. This compromises the muscles on the upper side of your forearm by shortening as well as twisting them. To avoid this, you may shrug your shoulders or bend your elbows more, cramping the muscles in the elbow or upper shoulder. Now you begin typing away for hours.

As a result, the muscles that are already shortened become overworked. Usually, this happens in the muscles of the forearm, which support wrist function. The MCC becomes aware of this fact via the painful feedback in the part of the nervous system that connects these muscles to the brain. As a survival response, it decides to back off using the sore muscles. The result is that these muscles begin to lose strength, due to fatigue. But our project is only halfway completed and must be finished. The MCC selects other muscles to compensate for the original muscles in order to keep going. This compensation pattern in turn becomes the new way to type. What you usually notice is tense, sore muscles, usually in the shoulder, upper back, neck, and jaw, as well as painful joints where the muscles are no longer strong and active, usually in the wrist, elbow, and hand.

You have developed dysfunctional motor coordination. Your brain has literally forgotten how to use these muscles in their natural, efficient patterns. The compensation patterns are not as efficient, which strains both the muscles and joints involved. These patterns, or motor programs, must be reprogrammed properly in order to resolve the problem in a timely manner.

How AMC Quickly Resolves the Causes of Pain and Lost Function

In Applied Motor Control, we follow two main principles:

1. Weak and tight muscles are symptoms of dysfunctional motor coordination. Simply treating these symptoms will not result in quick resolution of the problem. The condition will persist, or may even worsen over time. At the very least, it will take a much longer series of treatments to obtain even minimal permanent improvement in your condition.
2. The source of a muscle problem resides in the nervous system. It is the quality of the MCC’s connection with each muscle that results in the symptoms of muscular weakness and tension.

Using a gentle form of direct muscle testing, Applied Motor Control engages the MCC in a two-way, kinesthetic conversation. For example, if practitioners wanted to check their clients’ ability to extend their wrists, they would apply a light force of perhaps two pounds against the back of their clients’ hands, while asking the clients to pull their hands back toward their elbows.

Using AMC, the practitioner:

1. Gains information about which muscles are weakened. If the wrist extensors were weak, the clients would not be able to resist against the pressure.
2. Determines which muscles are being recruited to compensate for the weak muscles. Using assessment techniques, the practitioner would determine which muscles were tensing up to compensate for the wrist extensors.
3. Enables the MCC to understand it was compensating and needs reeducation. When the wrist extensors test weak, the MCC is aware that it tried to activate them and failed. This initiates a neurological process called Motor Learning. During this stage, the MCC becomes willing to relearn how to succeed in activating the wrist extensors.
4. Then takes the MCC through a detailed, step-by step re-education (reprogramming) process whereby it learns once again how to perform each action in the most efficient manner. The practitioner releases the compensating muscles while the Motor Learning process is active, and then tests the wrist extensors again. When they respond better to the muscle test, the MCC interprets this as a successful reeducation process.

Once the reprogramming process is complete, the MCC will remember the regained function. It does this by storing the movement pattern as a "program" in Motor Memory, which is similar to storing a software program on a hard drive, so that the movement can be recalled on demand, much like starting up your favorite word processor.

Now the weak and tight muscles may be treated with any of a variety of soft tissue modalities in order to resolve the physical symptoms of tension and pain. The most rewarding thing for the client is that after reprogramming, the pain and tension are much easier and less painful to treat, and the results are much longer-lasting. Most people who come for treatment already have suffered a certain amount of pain. Why add to it?

When Is AMC Appropriate?

In an ideal world, you would come in for treatment at the onset of symptoms. A new problem is much easier to treat than one that has built up for months. It is much like a weed: if you pull it out when you first notice it, it comes out quite easily. If you let its roots get a deep hold, it is much more difficult to pull out.

The great thing about AMC is that if it is not appropriate for you at the current time, it does not work. This usually means that you need to see a doctor and get specific acute care first. It also means that you do not need to undergo a lengthy series of treatments, hoping you will magically get better. We either see noticeable improvement within the first two or three treatments, or that this isn’t what you need. If AMC is incorporated at the proper time during rehabilitation, you most likely will respond quite well.

You deserve to have your problem resolved as quickly as is reasonably possible. Also, at some point in your rehabilitation you owe it to yourself to help ensure that your suffering does not recur. In my practice, 90% of all clients have their original problem resolved within six AMC treatments.

AMC is also great for maintenance. As work stresses begin to show up as minor aches and pains, you could come in for a "tune-up" and be on your way again for a while. As I said earlier, a recent problem is much easier to work out than one that has had time to settle in. Your car needs regular maintenance, and you take it in without a second thought. Your body is far more complicated than a car engine, and it would appreciate regular maintenance, too!

About the Author

Howard Nemerov developed and teaches Applied Motor Control, and has written a book on the subject. During the course of his research he has developed treatment solutions for injuries to the hands, arms, and shoulders, as well as TMJ and low-back pain. AMC training is available for interested professionals. Corte Madera is in Marin County, about 15 minutes north of the Golden Gate Bridge. Contact him for more information or to arrange a free introductory assessment and consultation.