Commonwealth Club Speech on Muscle Learning Therapy (MLT) 


The following speech was delivered to the Silicon Valley Forum of the Commonwealth Club of California on 2/5/98. This speech is copyrighted and may not be duplicated in any form without consent of Dennis L. Ettare, MA.

>>> Updated 2/8/1999 <<<

To the impatient reader:

You may find the questions and answers at the end of this paper engaging and illuminating. They provide faster and to-the-point information while hopefully inspiring you to go back and read from the beginning. J

This speech was originally presented to an audience and has subsequently been edited in order to facilitate the written word. In so doing, new or corrected material as well as additional Questions & Answers were transcribed and subsequently added. D.E.

Dennis L. Ettare, MA
Biofeedback Associates of California (BAC)


Why is it that today, with an ever-improving workplace and increased attention to worker comfort, why are more people are getting injured than ever before? It wasn’t very long ago that people were sitting in worse workstations, doing eight to ten hours of data entry, using a mouse and a keyboard, yet not getting injured as today. Also, curiously, why is it that something as violent as breaking concrete with a jack hammer hasn’t produced the same quantum leap in injuries we have seen in the less physical environments of offices and manufacturing today?

Those curiosities eventually led to a better understanding of chronic muscle pain in general and specifically, repetitive strain injuries. For over 20 years, Biofeedback Associates of California (BAC) has provided a specialized therapy to promote the reduction of injuries, get people feeling better faster and yet all the while not affecting work porductivity.

BAC’s clinical findings have shown that when people are trained to reduce the muscle loading that occurs during work, there is an 80-90% success rate in reducing pain and keeping people at work, or at least getting them back very quickly. How that has been accomplished is what I wish to share with you today because the alternative (reduction of the workload or trying to change jobs) is seldom a practical alternative.

The two major questions we face today in health care regarding chronic muscle pain (such as repetitive strains), are the following: The first regards understanding the actual event at the tissue level and the second, most importantly, concerns how we can affect significant change.

So, without paralyzing ourselves with theoretical abstractions and solutions requiring fundamental changes in the human psyche, and without fooling ourselves that we can invent the perfect work site or magic pill, it is my intention to give concrete alternatives you can take with you today. Some readers will find these solutions quite different than anything heard before but at the same time it is my hope that they may recognize certain concepts, themes and problems starting to fall into place. In the end, I hope you will hear enough to jump-start the process of adapting real solutions to the real problems facing workers world wide.

Until recently, a major factor contributing to the lack of a clear treatment protocol has been the fact that researchers did not fully understand the physiology of muscle tension and muscle pain. They were also puzzled because they knew that pain can’t be felt in muscle tissue. That fact is due to our basic anatomy. In order to feel pain, you need free pain receptors in the muscle fibers. There just aren’t any free pain receptors in muscle fibers. Otherwise, you would feel pain every time you moved. Recently, however, the interesting mechanism by which people do feel muscle pain, along with the actual events that initiate it, have been researched and published. First, I need to briefly bring you up to date on what muscle pain actually is, as we know it today, and second, how its discovery has now, finally, opened a doorway into providing clinicians with the very method required to help reduce muscle pain.

The relatively few pain receptors that reside in your muscles are not freely accessible to their surroundings. They are protected by a hard capsule inside small anatomical sites called muscle spindles. They are about the size of a rice grain. These spindles, randomly placed throughout all skeletal muscles but more concentrated at the back of the neck, are filled with liquid and contain even tinier muscles called intrafusal fibers. And now getting to the main point, the muscle spindles contain most of your pain, pressure, and stretch receptors. The surrounding capsule protects those receptors from the constant movement of adjacent muscles. It saves you from feeling pain during simple movement.

It is very interesting, as research provides better answers, how those receptors can eventually become irritated. They have recently been shown to become irritated when people are overloaded, intense, focused, overworked, hyper vigilant, worried, and/or overwhelmed. That begins to explain why you often hurt more when you have more things going on in your life. It’s especially true at work where there exists an unrelenting drive and intensity surrounding workloads along with their accompanying responsibilities and pressures. Your pain, in other words, is not in your head. It is in your muscles. And it resides there because of real work loads, real responsibilities, and difficult goals. They are not imagined problems. They are very real because they come from the real world of what is expected of you. The proof of their real existence is that if you don't attend to those factors, you may lose your job. That seems like an adequate reality test to me.

Muscle spindles, can develop, over time, into very tender and painful areas. They can also feel sore, achy, and stiff. Inevitably, if they become very irritated, they can develop into what are called trigger points, or places of tenderness. In addition, they can feel like a ‘knot’ when the encased liquid inside the spindle moves less easily. Eventually, those knots can feel like a ‘golf ball’ when the band of muscles surrounding the muscle spindle itself also tightens. Your first reaction to that kind of discomfort will be to want a massage. Afterward it may feel better but it won't stop other spindles from starting up. In other words, if your workload has increased recently, but more importantly, if you have accepted that responsibility, you have a higher probability that you will hurt more. And correcting the hurt doesn't correct the origin of the problem.

I know, I can just hear everyone saying how tempting it is to accept more work when everything moves faster and everyone expects more. You may even feel it is politically correct to keep doing more, too. You also may feel it is impossible to refuse to do more work when your job may be at stake (that is a compelling argument). And finally, you may be right to worry. Between downsizing, work restructures, and industry moving to other parts of the world, you can’t afford an injury affecting your chances of survival.

Health care professionals have few options for the treatment of chronic muscle pain. They can inject the trigger points, or try to reduce the pain through massage, heat, acupuncture, medication, posture, education, exercise, or joint adjustments. In the end, however, those methods only help to get you through the moment, they don’t change the future. At best they provide temporary relief, as a bandage might. Admittedly, bandages do sometimes feel very good and they can serve the immediate purpose of getting through a recurrence. You may even need such a ‘bandage’ to just get through the week. But bandages are also very seductive. You may get so used to them that you feel you no longer have a problem.

Sooner or later, however, you will need to correct the inappropriate muscle behavior that got you into trouble in the first place. There aren’t any passive interventions or therapies (i.e. the things people do to you) that can change inappropriate muscle behavior while you work. Taking breaks are nice but they can't undo damage already done. And ‘bandages’ certainly can’t change excessive muscle loading. If you inject or massage an active muscle spindle to get rid of pain, another spindle, inevitably, will be available to take over the job of hurting. If you are behind in your work or you have bitten off more than you can chew, even specific medication that relaxes muscles can’t force you, against your will, to relax.

The real culprit, the origin of what we today call "muscle pain", is due, principally, to the following: 1) an increased workload, 2) a more constricted work site, 3) along with faster tools, 4) an acceptance of increasing responsibilities, and finally 5) the body’s response to all of this with an increase of sympathetic activity firing into muscle spindles. In other words, the real culprit is real life. But the mechanism by which real life sets you up for injury may be due to a combination of two factors. The first involves mechanical insults to the tissues and this is the basis for the ergonomic solution to the problem. But there is recent research suggesting another mechanism contributing to the problem and it comes directly from an increased hyper vigilance and intensity on the part of the 'driven' worker to perform ever faster and better.

The amazing thing is that the highly performing, conscientious, and focused worker has recently been shown, and proven, to be more likely to get injured. In other words, the better workers are more likely to get injured because they try harder. More on how that happens later. But don't get discouraged. I am leading up to a better understanding of the problem so that you will understand and relate to the surprise solution waiting for you.

The combination of trying to do more and doing it faster can, in other words, be deadly. Together they contribute to an increased vigilance and arousal level (chemically) of the body. But since workers can’t afford to reduce the workload or eliminate responsibility in today’s world, they invariably try to solve the problem by exercising harder, getting stronger, trying to avoid thinking about the pain, putting up with pain, and/or expecting the health care system to fix them. Well, I hate to be the bearer of bad news but healthcare really has no solutions for you. In fact, they are just as puzzled as you are (at least the informed and honest ones are). What’s more, the system doesn’t like dealing with these problems because it has no real solutions. It prefers dealing with injuries it can help. There are no quick fixes for chronic muscle pain and consequently you will be lucky to just get good eye contact from those in health care. The muscle physiology of the problem doesn’t allow for quick fixes. That’s the bad news. But there is good news.

The good news is built upon the observation that when muscle loading is reduced during work, the body’s chemistry and electrical activity also changes. Usually this can be only accomplished by stopping or reducing work loads and/or responsibilities. Recovery inevitably occurs over time when that happens. In fact, that seems to be the only way recovery, until now, has had a chance of occurring. Unfortunately, most people don't have the luxury of being able to reduce workloads, or become irresponsible, change jobs and/or wait around for years to feel better. Everyone hopes for the discovery of the magic pill allowing them to work hard yet feel no pain. Everyone is so overwhelmed by work and worries that we all hope for the quick fix.

Wouldn't it be wonderful if someone could just train us to work hard, use less muscle and, because of the training, not get injured? If we could just FORCE muscles to behave themselves, then recovery would naturally occur while we did our work.

Of course, the real stumbling block in getting muscles to behave themselves stems from the fact that few people know how to force muscles do the right thing, especially within a tough work environment. If the training isn't forced or induced, as compared to getting people 'educated', there isn't much chance of it generalizing into the intensity of the real working world. So, in the end, the inevitable difficulty lies not in understanding the problem (although many still have missed that point, too) but instead in how to get the muscles to behave themselves while at the same time not altering the quality and quantity of work.

To that end, BAC has developed over many years what has turned out to be a very effective training algorithm. The specialized training was developed from the observation of other professions requiring equal demands on the musculoskeletal system. They included various training methods observed in sports, music, martial arts and other disciplines demanding excellent muscle control during severely stressful conditions. The emerging model has(over years of development) successfully transferred that same training model so familiar in sports or music into the intense and challenging world of the work environment.

The hypothesis comes from the observation that if training for a demanding sport or musical performance can prepare you for the extreme conditions of competition, why can’t it also prepare you for the incredible demands of work? At the same time, why can't training also help those who are already in pain and injured? After all, since evidence already exists supporting the fact that muscle loading causes/irritates pain, it makes sense that reduction of that loading along with reduced sympathetic tone will also reduce a major component in the origin of chronic pain.

The training concept (or solution) was at once both simple and complex. The simple part was based on standard practices of just putting people through specialized tasks of repetition and reinforcement and then making sure they showed up for the training appointments. The rest happened on its own. Performance became automatic and assured excellent results even if the person had little coordination or little command of English. Performance under duress was the goal for everyone. Very similar to the environment workers face today. The more complicated part, instead, was in finding the experts to do the training. The same difficulties can be found in teaching a musical instrument or any other activity requiring muscles. Biofeedback Associates of California has developed a formula, or method, to help reduce the contributing factors in muscle pain. It is called MLT or Muscle Learning Therapy/Training. Biofeedback instruments are used as a tool to facilitate the learning process along with a very complex set of training interventions.

The requirements in a typical work place today are much like those of the well-trained athlete or musician. Workers have the same needs and are under the same kinds of pressures. Workers have to deal with performance, stress, unreasonable expectations, peers and subordinates wishing to take their place, personality conflicts, home conflicts, age, mental fatigue, and, eventually, physical exhaustion.

How can we expect untrained workers to succeed unless they, too, are given the skills required to perform? The worker requires, and eventually should expect, excellent training and instruction to avoid injury on the job. People are not born knowing how to play soccer, or ride a bike or how to correctly use muscles while working, unless they are taught. Since we still find people getting injured in ergonomically corrected workstations, evidently the complete solution has not yet been found. The external environment has been addressed. It is time to address the internal environment, i.e. the world of muscle loading and sympathetic overload.

Using again the sports analogy, you don’t go out and buy a better tennis ball in order to become a better player (although manufacturers of tennis balls - or ergonomic keyboards - will have you think so). The solution, instead, ultimately depends upon improved performance through training. In today’s work environment, instead, the only training offered by industry involves the use of specialized tools along with some vague, inconsistent idea of where to place those tools. That’s like saying the secret to baseball is in how you hold the bat. Never mind the hours of repetitive practice and sacrifice. Never mind motivation, focus and drive. Never mind the physical and mental pain often experienced while training. Never mind the skills resulting from trial and error under severe pressures. But especially never mind the skills, insight, and wisdom of the coaching. Just buy a better word processor and you will get better literature. Become an accurate typist by getting stronger arm muscles and a wrist rest, and finally, a better desk. Taking the analogy further, to stop having arm pain, all you need is stronger muscles, the correct keyboard and good posture. Some things don't even pass the straight-face test.

The biomechanical and biochemical events in chronic muscle pain, of which RSI is a major pain producer at this time, are much more complex than once thought. But happily they are now becoming clearer while at the same time, are offering solutions. The solution involves more than just good posture, correct tools, and healthy muscles, however. Those have always been the basic rule but we STILL have injuries when all those are OK. It is now apparent that what we also need is professional training of the workers so that they can perform under pressure, arrive at the end of the day less exhausted, and without injury. Bear with me while I give you just a minute of what we think may be actually happening in the affected tissues I have just described and where training can make the difference between success and injury.

When you’re overwhelmed, upset, in a hurry or just having an ‘intensely’ good time, the part of your nervous system which responds is called your sympathetic nervous system and over which you have no direct control. The intensity of the event can come from within us or it can come from family, friends, co-workers, subordinates and/or superiors. Interestingly, it was only recently we discovered that sympathetic nerves actually innervate skeletal muscles in the first place. We have known about their effect on arteries for many years. For example, when you are overwhelmed, your arteries constrict as you go into a ‘fight or flight’ response. It is the body’s defense and protection against dangers. The sympathetic nervous system is responsible for getting the chemistry of the body ready for resolution of a perceived problem. If resolution doesn’t happen, you stay in that highly vigilant, aroused state until something changes. Recent research has now proven that the sympathetic nervous system does MORE than simply shut down the arterial blood flow. It was originally discovered by a research group in Italy as well as reinforced by recent research here in California by Richard Gevirtz, PhD and David Hubbard, MD, that those nerves actually terminate directly into the same muscle spindles I mentioned earlier. They wind up right where your muscle’s pain receptors are located! That’s why you hurt more when you are more upset, overwhelmed, intense, and driven. It also means that if you don’t resolve that intensity, the muscle spindles get too much stimulation and you have a higher probability of injury or lingering pain. That pain is there for a reason. It is there to warn you.

OK, I know, you’re thinking here we go again, blame it all on stress. But it’s not just stress. It is the desire to do very well, it is having a high work ethic and the need to please the ones who control your future. But also I must remind you that the stress response from social pressures is triggered from a multitude of social cues and manifests itself in ways that we are only now beginning to understand.

Luckily, from this complex problem comes a unique solution. It doesn’t require mind tricks or sophisticated forms of denial in order to learn how to feel better. Instead, it comes in the form of learning to reduce physical and mental overload the same way you would learn to throw a ball or type a letter. It comes from the simple practice of muscle control, NOT mind control. That’s why MLT is easier to learn and allows everyone the chance to reduce one of the major causes of muscle pain. In other words, muscle overloading would be a lot easier to control if one could learn a muscle (motor) skill that reduces overloading for you. And finally, it would be even better if that skill didn’t require the stoppage of your work or require having to remember to do it in the first place. That type of training already exists and is called ‘Practice makes perfect’. You do it for sports, to type, play an instrument or learn to walk. But in the field of muscle pain we must call it something else or people become confused. Therefore I have called it Muscle Learning Therapy (MLT) and it works the same way. The difference is that instead of watching a thrown ball or listening to notes played, you watch a computer screen and do what the therapist tells you. The rest happens automatically. What is more, it lasts a life-time. Even if you want to forget what you learn, it is impossible. Just like it is impossible to unlearn how to ride a bike.

To this day I don’t know why that solution seems so far out of reach to health care professionals. We use it all the time when we learn to drive, throw a ball, walk, type, dance, play an instrument and/or learn a sport. The only difference is now we must learn to develop those skills while working, at home and during sports and leisure time.

The drive to transform a generalized training concept into a specialized method for worksite training was my main focus 20 years ago and became a reality fifteen years ago. There is actually now preliminary research supporting MLT's efficacy at changing and maintaining the behavior of skeletal muscles while people are working. So the remaining issue is, how do we get training to actually show reduced pain or reduced injury rates at work?

The explanation lies within the physiology of specific nerves and the muscles they innervate. When put under certain pressures, the body does not always respond in positive ways. The chemical and physical response, the heightened arousal your body feels when you are overwhelmed or in a hurry, although a normal one 2 million years ago to insure your survival, is no longer a critical factor. It is called the fight or flight response. Nature gives you a built-in mechanism to avoid danger of injury or death.

In today’s intense working world, it not only has become an exaggerated response, it is completely unnecessary and can actually set you up for injury. But your body does not know that in front of you is a computer, not a saber-toothed tiger. Your chemical and physical responses scream for resolution. But you, instead, sit focused and resolute to finish your work. And as you ignore the pleas of your system to do something, the chemical response continues firing into muscle spindles and creating an extremely sensitive environment ready for pain. Injury eventually occurs when you have reached a threshold wherein your tissues can no longer take the protected abuse. Now you hurt. That is nature’s way of trying to get your attention and get something changed. Instead, you get an ergonomic evaluation and reduce the irritants in front of you by putting everything in their proper place. You now hurt less. So you ignore future warnings because everything should be ok. Until you hurt so badly that you can’t ignore it and you go to a physician. He/she has nothing from medical training to draw upon except medication and rehab. Medications, exercise – exercise, medication. You are in a rut and soon you are lucky to get good eye contact from your doctor or therapist. Welcome to the world of chronic muscle pain and the saga of trying to find the magic potion to end your pain. Of course, you are still working very hard and trying to keep your job. Or, you are on disability and wondering what kind of future you will have.

Unfortunately, evolution is having a hard time catching up with our rapid technological changes. Eliminating that chemical overreaction may take another couple of million years and we, instead, need to go to work in the morning.

Today we are under pressure to do more work in less time and with more responsibility than ever before. We sit in a confined worksite with all our material right at our fingertips along with a computer working faster than humans are made to go and, unfortunately, with little opportunity to get up and fight the battles our pain is emphasizing.

Through our aches, pain, and soreness the worksite is actually giving us a signal that a problem exists. The confusion lies in the fact that the worksite is, in effect, only part of the problem. So it is only part of the solution. And TRAGICALLY, WE SEEM TO BE CONFUSING THE WARNING SIGNAL WITH THE PROBLEM ITSELF. For example, if speed bumps on a road were to cause you, all of a sudden, to become annoyed or even to give you pain, you would quickly want them eliminated or moved. But what of their function as a warning device that you need to be careful ahead? Removing them doesn’t eliminate their message, "slow down/take heed". The warning itself, therefore, is only a small part of the big picture, just as your workstation is also only a small part of the problem. The keyboard is simply warning you of the existence of a bigger problem looming ahead if you continue on the same path.

In other words, the work surface and all your tools act like a trip mechanism, an early warning device, not originally intended to be such, but nevertheless functioning like one. Consequently, obsessing only over your keyboard or chair or work height or the tools you use is missing the point. You might as well be obsessing over the road bumps as you incorrectly assume they are your only problem. Especially if the ‘bumps’ cause pain. Why was it that sites were worse ten years ago and people weren’t having as many problems? The only variables that have really changed are that you have more work, more responsibility and less time to do it all (due understandably to downsizing and cost containment strategies).

Finally, it also needs to be noted again that those people injured are the ones who accept extra work, try harder, and become very focussed and driven – in other words, the good workers. And management itself isn’t immune, either. Even your position in the company can’t insulate you from having pain. There are no sacred cows avoiding this injury. Management gets it, insurance adjusters, programmers, physicians, and CEOs get it. Surgeons, librarians, police officers, house wives, teachers and newspaper reporters get it. The only ones that don’t get it are those who deny they have it or who are so naturally relaxed they wouldn’t get anything.

Years ago we used to constantly have to get up to get our work; our computers and software moved slower, our phones were slower, in fact ALL our tools were slower. We even had time to go to the bathroom. Today, we not only don’t have time to go, we’re so overwhelmed we don’t even realize it when we need to.



Muscles can be taught how to reduce the overload they are under and yet still allow you to continue working. The teaching or training method involves learning, through repetition and reinforcement. It trains how to reduce the muscle loading in the areas that count: the neck, shoulders, back, arms, and hands. But it is critical that it be reduced DURING work, not just during designated rests. Ten-minute breaks can’t go back in time and correct what has already been done. Taking a break is important but not as much as reducing the extra muscle loading along with reducing sympathetic activity at the time you do the work. By correcting overly responsive muscle behavior, that is, by reducing muscle sympathetic loading during work, we have the hope for long-term change. How that occurs is difficult to teach but it is not difficult to learn.

Biofeedback Associates of California has been doing that kind of muscle training for over 20 years and with excellent results. It is called Muscle Learning Therapy or MLT. Its limiting factor has been that not all doctors and insurance companies know of its existence. MLT forces the muscles to become more efficient while at the same time helping to reduce the major contributor to the problem, i.e. the sympathetic response or the causes from being rushed, overwhelmed and overtaxed. MLT should not be confused with traditional biofeedback, however. Traditional biofeedback tends to use more imagery, insight, cognition, and understanding. Typically it doesn’t rely on a structured, finite and predictable training model. Even those therapists using EMG instruments to point out what people are doing wrong are engaging in education, not training. MLT is, instead, a set of unique training interventions, supported by research, with over 20 years of development, which just happens to use muscle biofeedback because it alone affords the fastest way to learn. MLT uses sEMG (surface electromyographic) biofeedback to promote learning and to document successful training as it happens.

The technique is based solely upon a training model. It forces learning by completing rapid, accurate and complex tasks while the person watches his/her own muscle graphs on a computer screen. In so doing, it forces the brain to connect the feeling in the muscles to the behavior on the screen. Finally, and most importantly, it becomes an automatic response through the process of repetition and reinforcement.

It is essential that it become automatic because no matter how intense the real world becomes, long term change in symptoms will occur only through permanent changes in behavior of muscles under duress. Any coach would have to do the same in order to teach tennis, throw a ball or type. Interestingly, no one, to my knowledge, has taken the training concept to the world of soft tissue injuries for chronic muscle pain and the reduction of muscle loading. At least not to such a structured, finite and successful training strategy or algorithm along with research to support its specific interventions.

Another factor resulting in increased workload has been continuous downsizing of companies. Everyone winds up doing more work in less time and with more responsibility. Eventually, the ones that accept that responsibility are the ones getting injured. Those who get injured, therefore, are the ones with a high work ethic, those who are focused, challenged, willing to accept increasing workloads, those who become very involved, and are willing to sacrifice. The best workers are getting this injury. And it has become a worldwide problem.

The problem stems from the fact that our tools, computers, software and support systems are so much faster than they used to be, that, as a result, we humans are now the weakest link amongst our tools. We are playing catch-up to them and it has started to take its toll on our ability to withstand increased workloads. We have reached a threshold that is being expressed by increased injury rates.

A recent pain study found that of all the patients entering a primary care facility with chronic muscle pain, only about ten percent were treatable and diagnosable using standard medical procedures. In other words 90% of the problems were found to be from other than medical origins. That was the result of a study done at the University of Washington pain clinic and reported by a Professor Loesser. He pointed out that 90 percent of those presenting with chronic muscle pain to his clinic had an origin to their pain that MDs were ill equipped to recognize and treat and that had probably originated from increased social and work pressures. It was in response to that need for many years that BAC has worked hard to reduce the sympathetic and mechanical effects from the increasing pressures we face, while still keeping people at work.


A final cautionary note and a prediction:

Biofeedback Associates of California has noted that many of its more recently injured patients have presented with ergonomic changes already implemented at their work site within the previous 6 to 12 months of their arrival at our door. Apparently, as work sites become more ergonomically correct, there results an initial honeymoon of seemingly reduced symptoms as well as fewer claims reported. We have, at BAC, in fact noticed such a tendency. But we are also seeing an increase of the severity of patients injured after ergonomic changes were made. They present with more intense symptoms than those sent to us immediately upon feeling the first signs of discomfort. Apparently, the temporarily reduced symptoms due to ergonomic improvements have inadvertently given workers permission to work even harder to make up for lost time and/or to show their appreciation for feeling a little better. But those patients are now showing up anyway. Unfortunately, they seem more injured than the ones referred to us as soon as the first symptoms appeared when, as yet, no ergonomic changes had been made. In other words, the injury occurs anyway, it just takes a little longer when corrected workstations temporarily reduce symptoms. Evidently something is still missing. In the end, it winds up costing everyone much more - professionally, economically, as well as emotionally. We hypothesize that it may be due to the fact that the ‘early warning system’, the cluttered and bad worksite, was the trigger mechanism pointing out only a part of the problem. After the work site was corrected, nothing was done to reduce the bigger problem of the load on the workers’ shoulders—figuratively as well as literally.

So, what is the solution and prediction? Well, since we can’t reduce the workload and still remain marketable in today’s world, the logical solution would be to teach people how to reduce the muscle loading that occurs during work. Industry spends time and money training people to do their jobs, why not spend a few pennies more and train people how to reduce the mechanism responsible for most of these injuries before they happen? Or at least let’s allow them MLT training as soon as symptoms occur. It will wind up being less expensive for everyone in the long run.

And finally, what is my prediction? My prediction is that unless the external world (ergonomics) is combined with a program to teach workers how to take care of the internal environment (muscle loading and sympathetic activity) there will never be a long term change in repetitive strain injury rates or chronic muscle pain. Until ergonomics is taught along with the reduction of skeletal muscle loading, the symptom plateau observed recently from broad ergonomic improvements, is, in retrospect, going to become just the quiet before the storm.

 Question and Answer Period:


Bob Telleria (For Those in Pain, Inc.): Dennis, can RSI’s be designed out of the workplace?

Dennis Ettare, MA (Biofeedback Associates of California): You can’t design a work place that reduces workload and responsibility but you can train workers the skills needed to minimize the effects of muscle loading. The ultimate solution should be a combination of an ergonomically correct site plus workers trained to reduce muscle loading while they work. The work place was even worse fifteen years ago, as I mentioned today, when people were doing data entry, under worse conditions, and using a mouse 8 hrs a day, yet people were not getting injured as often. The problem, instead of being the work site, has become the increased workload and its associated responsibilities, due to downsizing, as it increases the burden on everyone, including management. As long as we have people who are conscientious and want to do a good job, and are being given more work to do in less time, and are NOT getting trained how to reduce the loading on their body, it’s not going to change. Unfortunately, you can sit in a perfect workstation and still get injured because the workload and resulting sympathetic response hasn’t been changed, just the keyboard, chair or whatever. The mechanism promoting a heightened arousal state (the sympathetic response), as you try to get all the work done on time, is driving the key system promoting soft tissue injuries. With the continuous sympathetic firing into those muscle spindles, the injury inches closer and closer to the threshold until one day you push yourself right over that edge. You do not know how close you are to the edge until you are over it and falling rapidly. But it’s never too late to stop the fall.


Telleria: Tell us about the relationship between RSIs, personal risk factors, workplace design, and methods and awareness training.

Ettare: The only awareness training that I have found to give long term results is the kind that changes behavior. No matter what happens, if you don’t affect behavior you’re not going to make any long-term changes in anyone’s health. What I look for ergonomically is to make sure the workstation simply stays out of the way of the worker or patient. Since the workstation cannot do anything actively, it should be there to assist the worker in reducing muscle loading and maintain a reasonable physical configuration during activities. The place for active learning involves teaching and training the worker how to reduce the muscle loading as well as the intensity and the drive that occurs at the workstation in order to avoid the injury. Injury has less to do with what’s in your way and more to do with your focus, high work ethic, work load, and intensity of purpose, sensitivity and drive. The physiological response within the body needs to be reduced while still maintaining focus, drive, challenge, and swiftness. In other words, you need to work hard while maintaining reduced muscle loading in the neck, shoulder, back, and arms. But that is a control factor, not a rehabilitative one. You don’t become a better typist by getting stronger. In the end it comes from a motor (or muscle) skill, not psychological, attitude or mind-skill.

At the end of the day, these same people who are hurting are going to have to get into their car, drive home through some of the worse traffic, take care of the house, and possibly work on more computer duties. What happens there? What happens when you’re washing dishes, combing your hair, buttoning your shirt? There is a constant irritation just as if you were at work. The solution, therefore, must include a learned skill that is used with everything you do, and goes everywhere you go. The one absolute fact about muscles is that they tend to follow you everywhere you go. So you better teach them how to behave under stressful conditions or your problem will follow you as well.


Telleria: Can you correct the problems with good posture, exercise and a good workstation?

Ettare: No, you need more than that. You can be physically very strong, sit in perfect posture and at a perfect workstation with the perfect boss and perfect co-workers and still be overwhelmed and/or coiled up like a tight spring. Externally you can look picture perfect but internally, unless you reduce the muscle activity along with the resulting sympathetic tone, you cannot address the whole problem. But the problem we face when we train people comes from the interesting fact that it feels very uncomfortable to work hard and be relaxed at the same time. The concept of "relaxed", to many, feels sluggish, slow, and non productive. It’s very disconcerting for those who have associated hard work together with tight muscles to, instead, be working and relaxed at the same time. However, as people learn the motor skill of relaxing while working very hard, the brain becomes spoiled and rarely allows the return to previous conditions. When you are trained well, you can’t ‘forget’ what you learned, just like you can’t forget how to walk.



Question: Why is it that my symptoms come and go? Why don’t I just have pain or not have pain any more?

Ettare: This soft tissue problem is less an injury, within the strict medical definition, and more an increase of tissue sensitivity or a lowered set point for feeling pain in those muscle spindles. What you feel will depend on many variables which we don’t have time for right now but it is very typical for soft tissue pain, or muscle pain, to be susceptible to weather changes, hormones, work overload, viral infections, or even diet. With that in mind, you will be sore, achy, have pain, pins and needles or numbing during various times of the day and under various conditions, all of which will drive you crazy if you look for cause and effect. There just isn’t anything obvious to the lay person. For me instead, after thousands of patients, I see a definite pattern, a certain predictability.


Question: Why is it that some of our employees hurt even when they are not working?

Ettare: The activity that gets people better is not the cessation of work, it is the reduction of responsibility or the reduction of the sympathetic nervous system’s response to responsibility, that gets people better. Being homebound may cause some people to get even more worried. If you are not working but you are concerned about everything that goes along with it, plus you still have to open cans, open doors, shake hands, drive, comb hair, button, write and much more, then you will hurt anyway. Nothing has really changed except your location. The solution is not just the reduction of work, either. Doing better because you are not working is not my definition of success. Success is being at work, doing everything you must do in order to keep your job, feeling fewer symptoms, and not being worried about your future health. The only thing that can change how the injured worker feels is showing how symptoms are getting better and that work is not suffering because of it. That is not accomplished by getting stronger or getting a better keyboard. That’s accomplished through appropriate training.


Question: I am injured and am seeing a doctor. How long do people take to get cured with what you do?

Ettare: As soon as there begins a change in the physiological response to your everyday workload, and that you actually start reducing muscle loading, you can expect changes within the first few weeks. But if you define ‘cured’ as the absence of all pain, then you have an unrealistic definition of success. Success is defined as feeling fewer symptoms, being able to work your usual amount, still having recurrences but they are now getting fewer and less severe, recognizing that pain comes and goes, and knowing that pain is now no longer dangerous. With those facts in mind, we find that your pain can start reducing notably by the second or third month but you will not be out of the woods for several years. Yes, years. That doesn’t mean, however, years of pain and misery. It just means episodes that will continuously get better over time whereupon you will arrive to a point of long plateaus of no change, worried again that you will never get ‘cured’, and then you will improve another notch and start another plateau. That is why having someone ‘coaching’ and training you realistically, is essential for long term recovery.


Question: As a representative of a very conscientious industry, we have spent a lot of money on ergonomic changes. Now I hear that the worker also needs to be trained. When is this going to end? How long will industry put up with having to foot the bill?

Ettare: The real question should be, where am I getting the most for my money?. If you make reasonable ergonomic changes and train the person how to reduce their intensity at the their work site, you will have a cost effective program. Remember that this whole problem is in transition, where cost-effective solutions are slowly going to be the ones that survive. You are right in the middle of change, so it seems unfairly confusing. At some point, you will need to use your own common sense. Since this is not a medical problem, the solution will make sense to people giving it some thought. I know you hear many opinions giving you such different responses but in the end, everyone is just playing with bandaging the problem. Now is the time to start recognizing that unless you change the behavior of these workers, or lower the workload, you will never really get anywhere. Ergonomic chairs alone just wont’ cut it. The problem is immensely more complex than that.


Question: Why can’t we just buy that biofeedback equipment you use and let everyone learn at work or at home?

Ettare: Well that’s like asking why we can’t just go out and buy great word-processing software so we can produce great literature. Or, it’s also like asking why you can’t just buy a professional basketball so everyone will automatically learn how to play professional ball. Biofeedback equipment is not MLT. Muscle Learning Therapy only uses that equipment as a means to an end. The graphs on biofeedback equipment, or the ball on a tennis court, are only going to be as good as those who interpret the behavior and then give you personalized training to make changes. You can’t avoid good, professional coaching if you want to learn a motor skill such as Soccer. Anyone who has coached an athlete, or taught typing skills, knows how difficult it is to keep people focused, answer all their questions, their doubts and anxieties and keep them motivated. In addition, you might also ask, what does a physical skill have to do with learning to relax? Accomplishing the reduction of muscle loading at work is not something you do in your head. It is a motor skill, just like throwing a ball or typing. The only way you can learn it properly is to get the right training. An operant conditioning model called MLT has been used successfully for over 20 years to do just that. It was developed because nothing else seemed to make a long-term difference in people’s pain and functional capacity. The equipment doesn’t perform the training, specialists do. I know that sounds self serving but just go ask a coach why you can’t go get a pair of ice skates on your own and learn just as well. I wish I could just sell equipment and get the same results. Instead of being here on this rainy evening I could be sitting on my yacht and telling people to read my book and buy the equipment.


Question: Why is it that one day a specific activity will cause me to hurt and another day the same exact activity won’t, or not as much?

Ettare: That is because it is not the actual activity that gives you the problem. The activity just happens to be the trip mechanism at the time, the irritant at the moment. That is also why it is a mistake to blame whatever you are doing as the culprit. Keyboards, chairs, and desks are often blamed because they are on the front lines and are the most obvious. But they have very little to do with the fact that you are overwhelmed by work and responsibilities. You could be using a microscope, threading a needle, or picking coconuts but at the same time if you had a lot riding on the outcome, you would be setting yourself up for injury.


Question: Can you train workers at their own work sites?

Ettare: First of all there isn’t a need to train at the work site because an effective training program such as MLT can do everything needed in an office. But for those who just wish to use MLT as a prevention program, such a program has already been successfully put into place to do just that. We can’t train on site those already injured but we can train the worker who is at risk. There’s not enough time to go into it fully right now but we have trained groups of employees so that later, at their own site, they can change some of the things they are doing wrong. In addition, we train employee volunteers we call ‘advisors’. The advisors become trained by us to watch and assist others and thereby allow a cost-effective front line of defense/offense for the employer. It has been very popular because we stay in the back ground and get involved for the more difficult problems while at the same time constantly upgrading the advisors with new issues and problems and solutions. The advisors can come to us when they get into trouble. They are also trained to know when they are in trouble or out of their depth.


Question: What are the jobs that are less likely to cause injury, in your experience?

Ettare: Well, point to any job you wish and I can almost guarantee you that we have already seen someone for a RSI or a soft tissue injury from there. It is a fallacy to think there is somewhere else you can go where you will have less responsibility or not have to use you arms or back. Your sense of doing a good job and staying focused and having a high work ethic, along with a very high workload and responsibility, has all contributed to the injury. Just remember that people today are sitting in perfect workstations, in seemingly calms environments (like a library), and still getting injured. We see police officers, teachers, Doctors, students, mechanics, office workers, programmers, managers, newspaper reporters, flight attendants, assembly workers, lab assistants, dentists, lawyers, and the list could go on and on. You would think a philosopher, at least, would be exempt, but they still have to correct papers and lecture. There is no escape.


Question: Can you recommend a keyboard?

Ettare: Yes. The only one we really liked was discontinued. It was originally the LexMark, then was called Options by IBM, and now the patent has been sold and we are waiting for the new ones to be made. They are called Gold Touch. But stay away from those with a wide wrist rest or where the letters sit in bowls or anything fancy. The people needing split keyboards are those who are very wide shouldered, have a large middle, or short forearms. Anyway, just keep in mind that the keyboard wasn’t the culprit to begin with. Your workload, a restricted work site, faster computers and high work ethic all did you in. To undo the damage takes excellent skills, time, and patience. Science does not have a way to speed that process up.


Question: Sometimes I haven’t done anything at all, nothing, I guarantee you, NOTHING, and I STILL hurt. How can that be?

Ettare: There are events, over which you have no control, which will effect your pain. I already mentioned this in my speech. One is the weather. If a low-pressure front comes in, you will hurt more. If you are fighting a virus, you may hurt more. If you are under a deadline you will hurt. If you have some kind of performance needs, you will hurt more. . If your workload has increased, you will hurt. Finally, anything promoting fluid retention will cause you to hurt. It could be the day’s heat if you don’t perspire easily, or it could be the hormones from being premenstrual. All these things have nothing to do with your work or anything else in your control. I could go on and on. Just don’t try to pin things on events. You are looking for cause and effect. That is a fruitless venture. Stop it. You do it from the assumption that if you could find a cause, you just need to stop it and all would be fine. Well, what if I told you it was Life? Now what? So give it up and just concentrate on getting in control of it.


Question: If a worker’s symptoms are present while they work, should they stop and wait until they heal?

Ettare: Healing is only present when there is damage. RSIs aren’t really damaged tissues in the classical sense or we would see everyone healed within a few weeks. If open-heart surgery is healed in 4 months, how can RSIs go on for years? It just doesn’t make sense. In fact, the muscle spindles I spoke about earlier are irritated but not damaged. So getting stronger won’t help. Adjustments or massage won’t help. They feel good and are great bandages, but they won’t change the type of behavior getting you in trouble. No, the solution is not to stop working but to instead reduce the muscle loading during work.


Question: What exercises do you recommend to get stronger so we can avoid these injuries?

Ettare: I was just telling the person before you that there is no exercise for this problem. Trying to get stronger isn’t the answer, either. Especially if you use your hands or arms with weights, pulleys, elastic bands, or squeezing putty, you will just wind up prolonging the problem. Now don’t get me wrong, it may even feel good at first. To some, however, it is immediately painful but they are told ‘no pain, no gain’. In a soft tissue injury, that is silly. Increased endorphins and circulation will always feel good. But in the long run, you will just keep irritating tissues more. The only movement I find very helpful for a general good health is Tai Chi. It will promote balance, strength, relaxation, movement and general control. If you also learn through MLT training to reduce the muscle loading it will be a formidable combination for general good health.


Question: Why is it that you didn’t address Carpal Tunnel itself in your lecture?

Ettare: Because Carpal Tunnel is not a repetitive strain injury. The incidence of CT in the general population is about the same as it is in the population of those with RSIs. That pretty much supports the fact that CT is going to happen to a certain percentage of people no matter who they are or what is already wrong with them. In fact, CT is 99.9% curable with surgery. That is not the case with most RSIs. If you still have symptoms after surgery for CT, you were either misdiagnosed or you ALSO had RSI and it is that portion that continues to hurt. You can, in other words, have both. It is very confusing, I know, but the lay public has used CT as a label to identify ALL RSIs. It is unfortunate and wrong. Even when you have a test, the EMG test can be tricky to interpret correctly. There are false positives and negatives. Surgery should be your port of last resort, not your way of getting better fast.


Question: What are the early signs we should watch out for?

Ettare: The early signs are very subtle and most people often miss or discount them. They begin with a slight ache in a hand or arm or neck and go away over lunch time. Then, at some point, they will be less by the time you are home. You may also feel headaches, shoulder, or backache. They may just be fleeting moments of discomfort that are soon forgotten. Then, you will find they will need a night to go away and by the next morning you will feel better. At this point you may not feel anything for awhile, depending on your schedule and workload. But soon you may find a few areas that ‘tingle’ or may feel a bit numb. You may find yourself dropping a pencil or cup or piece of paper. Those symptoms, however, may be so sporadic that you won’t even count them. Again some of the soreness may return but this time you need a full Saturday to feel better. Then you may not feel anything and forget about the feelings completely. They may go away for a few weeks or even months. But one day, all of a sudden, you will notice that your ache or pain is back, more pronounced, and may have shifted to another arm or part of the body. By this time you may have mentioned it to a friend who will open up about his or her own symptoms. You both will just assume it’s part of working hard. You will be right, of course, but what you won’t know is that you are already in trouble.

Your workload or responsibilities may change and now your numbing or pain or pins and needles need a whole weekend to feel better. Eventually even the weekend doesn’t seem to help and you may have twinges of pain in your neck, elbows, arms, hands, thumbs or fingers. Sometimes those are the areas that start first. You are now getting worried and decide to take a small vacation to get better. A week later you are back from Hawaii. Not having felt any pain you assume you are healed and are ready to confront the world. Within a few days, or even hours, however, you will feel as if you hadn’t gone. Pain has started all over again. Now you are upset and wonder what to do. If you are lucky, you will tell your manager (unless YOU are the manager) who will insist you file a workers’ comp claim but more than likely you will go to your family doctor first. You should be summarily told you need to see your company doctor because it is an industrial injury. The GP may try a few meds or wrist brace until you both realize nothing is working. With more time wasted you will try to work with the medication your doctor gave you. In fact, you may even feel a bit better and are starting to get your hopes up - again. The medication may be an anti-inflammatory. You don’t really have a true inflammation but the analgesic, or aspirin-like quality of the meds may make you feel better. If so, everyone will be happy. Except that soon they won't work anymore or never really did. You have now ended phase one. There are 23 phases. Just joking. But you are, truly, only at the beginning. I should write a book but not many would read or believe it. Everyone today claims to be an expert. Even I am tired of hearing their claims. Anyway, back to your symptoms.

So now you are entering phase two. Your symptoms return and now you are really worried. But you are in denial and somehow convince yourself you are not one of ‘them’ (the ones you secretly made fun of for having silly symptoms in order to get out of work). You do everything and try everything. If someone would tell you to bathe in horse manure, you would instantly catch yourself contemplating the logistics of it. Time starts to takes its toll and soon you are a prime target for all the quick get-well schemes that abound out there. Anywhere from magnets to fancy chairs will greet your inquiries. After trying some on your own and failing rather quickly, you now exit the denial phase and enter phase three-reluctant resignation. You decide to put in a claim. There are more phases to come but I have answered your question. With a claim started, a new type of circus begins. If it were made into a movie, it would star Bill Murry.


Question: Why should we listen to your theories any more than all the others who profess to know the answers?

Ettare: Good point. Next question… Well, you are absolutely right about everyone claiming to know the answer or having the cure. I feel like a tennis coach telling everyone who wants to learn the game that they must practice hard, use an expert coach, and hang in there if they want to win. And along with my views are ‘other experts’ claiming that to learn to play better, instead, you just need to be stronger. Others are saying you need an adjustment or a special exercise if you want to win. Someone may even say it’s all in the diet, wear a magnet and you will improve your swing. In the mean time I’m trying to explain to everyone that unless you get out on the courts and DO something, behavior isn’t going to change and consequently you can’t expect any great ‘wins’ or change. Educating an athlete doesn’t get him or her more skilled. It just imparts more knowledge. That’s education not training. Finally, all the different kinds of ‘knowledge’ become confusing and you don’t know WHOM to believe. In the mean time, I keep on insisting that if you want to learn the game, the game of controlling those muscles, you aren’t going to get anywhere unless you train those muscles to behave themselves under pressure. In the heat of competition, you can’t stop the play to get an assist or remember strategies and moves. If they haven’t become automatic you are lost. In the martial arts, if you hesitate, you’re dead. It’s all practice, there isn’t much time to think.

Although everyone in sports knows you need to practice to succeed, those who are hurting don’t realize that they are in the same situation, it also takes practice to make changes. Both must recognize the need for controlling muscles. The injured think it’s a matter of getting ‘healed’. That would be fine if there were ‘damaged’ to begin with. They aren’t. The heath care system makes the assumption that if you aren’t better, you just haven’t seen enough people or tried hard enough. Or worse, they label you a ‘malingerer’. In the workman’s com arena, that is the kiss of death. The truth, instead, is that you just need to practice and wait for your newly acquired skills to do the rest. A good analogy is the management of hypertension. When your blood pressure is high, it means you are using appropriately learned skills to control it and keep it down. And when it’s down, it doesn’t mean you are cured. It simply means you are managing it well. The same holds true for chronic muscle pain. You must learn the skills needed to reduce that muscle overloading which is adding to the overall ‘hyper-vigilance’ and keeping you ‘on’ all day. It is that behavior which has been the main culprit in this problem and until you reduce it, I don’t care how you change your workstation, it won’t get better until you change the behavior. At some point, since the experts don’t have the answers, you may just have to use some of your native intelligence to see the similarity between managing your injury and managing things like blood pressure or diabetes. Soon, however, we may have some studies to give you some help.


Question: But don’t some therapies work better for certain people and not for others?

Ettare: Most are just rearranging the deck chairs on the Titanic. They are bandages. Some help the symptoms for awhile. Bandages may feel good to momentarily relieve unrelenting pain, but more long-term changes are needed. Otherwise, people will eventually catch on that no real change in their future will occur. Coincidentally, if you are lucky or if your workload decreases, the symptoms will seem to reflect the therapy you are in (acupuncture, TENS, adjustments, or exercise or whatever, seemed to make the difference). A good standard to go by is that anything that someone does TO YOU can’t have much of a lasting effect. Most can give temporary relief. Some help longer than others. In the end, however, unless the behavior of muscles is changed, or your workload is reduced, you aren’t going to change the future.

We have to stop now. If you must leave here with only one message, don’t start obsessing over the work place. Instead, start by looking where more long-term solutions lie. Look into training people and giving them the skills needed to survive the ever-increasing workloads, pressures and responsibilities.



Question: What time frame is needed for the training?

Ettare: Most people can be trained within 12 appointments. By the 4th or 5th appointment, many already have begun to feel the difference. The time takes about three weeks to feel the first changes but all training finishes in 6 weeks with the final 4 reinforcements spaced at different intervals.


Question: How does the training work?

Ettare: Tasks of increasing complexity are given and while watching their own muscle graphs on a computer screen, people soon become trained. The tasks are specific to, and are the reason for calling it, MLT. The objective is to increase the intensity and speed of the tasks until they have been learned well enough to become spontaneous during intense working conditions, and during various activities of daily living, sports, and hobies.


Question: Where do you do the training?

Ettare: MLT is only taught in the San Francisco Bay Area and Sacramento for now. There are offices in San Jose, San Leandro, Los Altos/Sunnyvale, Daly City and Sacramento Metro.


Question: No, I mean do you do it in an office space or on site?

Ettare: Actually, we do it in both. On site training is only for prevention, however. The programs are not very expensive but industry and insurance carriers are not willing to spend anything on training right now, other than for furniture and ‘education’. They like classroom instruction because they feel you can instruct 200 people at once and get it over with. It seems cheaper to them and they feel they get everyone over with in a hurry. That’s not how MLT works, unfortunately. It’s like asking if we could provide tennis lessons in a classroom setting to make it cheaper. Uh, sorry, that’s not how motor skills are developed.


Question: Why haven’t you trained more people to teach MLT?

Ettare: It takes a long time to become a therapist. I have seen it take up to two years to get really good enough to become somewhat independent of my constant supervision.


Question: How do you answer the question of MLT sounding like it’s a proprietary intervention just insure you of control?

Ettare: If everyone that attempted it would succeed, it would be great for everyone. Unfortunately, those that try and fail, blame their failure on the procedure rather than their ineptitude. I keep it proprietary because it insures predictable outcomes. In the end, outcome will be the driving force behind its ultimate acceptance.


Question: Who usually fails at MLT?

Ettare: Just as you can’t fail at leaning to type, you can’t fail at MLT. Some do take longer than others. But we have a success rate of about 90% because it is really up to the therapist to get the person trained, not the patient. The patient’s responsibility is not very great. Just show up for training appointments. The 10-15 percent that fail either have quit because they got better very fast or they didn’t get the improvement fast enough. Some just want to get fixed.


Question: Could I volunteer time in your clinic to learn MLT, as an intern?

Ettare: Teaching MLT to therapists is very hard and draining for us. The learning curve is not fast and we use so much energy that we can’t also take time from out patients to teach others right now. We are, however, expanding our program and may soon need help, so check with us later.


Dennis L. Ettare, MA
Director - Research & Training
Biofeedback Associates of California (BAC)
2211 Moorpark Avenue, Suite 210,San Jose, California 95128
408/295-2944 1-800-222-5552 (N. Calif) FAX 408-295-2997
rsi-bac@ccnet.com 1990,1999

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Last Updated: 02/06/99