Dr. Deepak Sharan

repetitive strain injuries

I have been invited by The Times of India, Bangalore to write a weekly expert column, to spread public awareness regarding RSI, Musculoskeletal Disorders, and School Health.

Non-drug remedies for insomnia
(New series in the Wellness Supplement)
Author: Dr Deepak Sharan
Bangalore, The Times of India, September 23, 2006
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Right posture keeps wrist pains away
(New series in the Wellness Supplement)
Author: Dr Deepak Sharan
Bangalore, The Times of India, August 26, 2006
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Prevention of heel pain
(56th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, February 5, 2005
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Self help measures for heel pain
(55th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, January 29, 2005
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What's causing your heel pain?
(54th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, January 22, 2005
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Calcaneal Spur and Plantar Fasciitis
(53rd Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, January 15, 2005
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RSI and Heel Pain
(52nd Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, January 8, 2005
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The Effect of Pregnancy on RSI
(51st Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, December 25th, 2004
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Factors causing RSI in women
(50th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, December 18th, 2004
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Is RSI more common in women?
(49th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, December 11th, 2004
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Air travel without pain
(48th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, December 4th, 2004
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RSI and Traveling by Air
(47th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, November 27th, 2004
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Symptoms of Myofascial Headaches
(46th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, November 20th, 2004
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RSI and Headaches
(45th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, November 13th, 2004
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Paradoxical breathing and RSI
(44th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, November 6th, 2004
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Releasing TrP's effectively
(43rd Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, October 30th, 2004
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Factors that relieve MPS
(42nd Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, October 16th, 2004
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Factors that aggravate MPS
(41st Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, October 9th, 2004
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Symptoms of MPS
(40th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, October 2nd, 2004
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The endless web
(39th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, September 25th, 2004
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Of triggers and trigger points
(38th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, September 18th, 2004
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Releasing your psoas
(37th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, September 11th, 2004
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Know your psoas well
(36th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, September 4th, 2004
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Benefiting from an AT Lesson
(35th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, August 28th, 2004
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Learning the Alexander Technique
(34rd Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, August 21st, 2004
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It's not Carpal Tunnel Syndrome
(33rd Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, August 14th, 2004
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Managing double crush syndrome
(32nd Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, August 7th, 2004
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Understanding double crush syndrome
(31st Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, July 31st, 2004
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Beating the backpack blues
(30th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, July 24th, 2004
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Sharing the child's burden
(29th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, July 17th, 2004
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The school's role in backpack safety
(28th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, July 10th, 2004
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The art of carryng backpacks
(27th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, July 3rd, 2004
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How to choose a backpack
(26th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, June 26th, 2004
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Backpacks cause bad backs
(25th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, June 19th, 2004
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Reflex Sympathetic Dystrophy
(24th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, June 12th, 2004
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Balanced sitting posture
(23rd Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, June 5th, 2004
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How to sit properly
(22nd Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, May 29th, 2004
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Why is sitting such a pain?
(21st Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, May 22nd, 2004
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Why do people work in pain?
(20th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, March 6th, 2004
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Tomorrow is RSI day
(19th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, February 28, 2004
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Work shouldn't hurt
(18th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, February 21, 2004
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Take care of your posture
(17th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, February 14, 2004
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Demystifying neck and back pain
(16th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, February 7, 2004
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Beware of thoracic outlet syndrome
(15th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, January 30, 2004
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Tackling myofascial pain
(14th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, January 23, 2004
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How does RSI occur?
(13th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, January 17, 2004
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Physical office factors
(12th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, January 10, 2004
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Work organisational risk factors for RSI
(11th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, December 20, 2003
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Psychosocial risk factors for RSI
(10th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, December 13, 2003
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Ergonomic risk factors for RSI
(9th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, December 6, 2003
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Symptoms and stages of RSI
(8th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, December 1, 2003
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What is RSI?
(7th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, November 22, 2003
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Call center ergonomics
(6th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, November 15, 2003
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A survival manual
(5th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, November 8, 2003
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Some health issues in call centres
(4th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, November 1, 2003
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Safety issues in call centres
(3rd Article under the "IT's your health" series)
Author: Dr. Deepak Sharan
Bangalore, The Times of India, October 18, 2003
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Kids need to learn healthy computing
(2nd Article under the "IT's your health" series)
Author: Dr. Deepak Sharan
Bangalore, The Times of India, October 11, 2003
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Keyboarding kids: generation at risk
(1st Article under the "IT's your health" series)
Author: Dr. Deepak Sharan
Bangalore, The Times of India, October 4, 2003
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Keyboarding kids: generation at risk
Author: Dr Deepak Sharan
Bangalore, The Times of India, October 4, 2003

Forget sleazy chat sites and violent computer games -- a more dangerous threat to children these days is the computer itself. The designers of computer workstations installed in Indian schools usually forget to take into account the needs of growing children --putting lakhs of children at risk for musculoskeletal problems like Repetitive Strain Injury (RSI).

For example, did you spot the serious health hazard in a recent photograph in the Times of India (`IBM introduces IT in 44 schools', Sept. 20)? The child is seen holding the mouse at shoulder level. Any child who uses this workstation for a few months is likely to develop a crippling and painful RSI, perhaps leading to inability to hold a pencil or play games.

There's little awareness or willingness to learn among parents, teachers and people who manufacture computer equipment and furniture. RSI tends to be trivialised: children do not spend long hours in front of the computer, their bodies are resilient, the aches and pains go away if they stop using the computer for a few days, and nobody has the money to buy a sophisticated workstation.

None of this is true. Even 30 minutes of improper computer use daily can lead to progressive and permanent structural damage to muscles, nerves and blood vessels. The awareness levels are low because RSI is rarely diagnosed in our children, which comes out of lack of awareness among parents and doctors in turn! Sensible ergonomic solutions do not require huge investments and usually existing facilities can be modified and improved upon.

Most children in Bangalore are now working on keyboards that are too high and incorrectly angled, looking sharply up at monitors, leading to neck pain and headaches. Many sat either far forward with their feet on the floor but backs unsupported or far rearward with their backs supported but legs left dangling. The former can lead to back strain and the latter to swelling and numbness of the legs and feet.

My ongoing research has revealed that three out of four among 1,200 IT professionals already have symptoms of RSI. I shudder to think what the incidence of RSI will be when the present lot of children, who have been (ab)using computers and video games since the age of three, grow up to be software engineers!

(The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI)

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Kids need to learn "healthy computing"
Author: Dr Deepak Sharan
Bangalore, The Times of India, October 11, 2003

As younger children begin using computers intensively they may be at even greater risk of injury than adults are because their bodies are still growing. Reports of schoolchildren in Bangalore developing repetitive strain injuries (RSI) have already appeared in the news media. However, parents tend to attribute children's complaints of wrist, hand, arm, neck and back aches to sporting activities or "growing pains" without realizing that the computer may have been responsible.

Adjustable chairs are highly recommended because children come in different shapes and sizes. Otherwise, a cushion may be placed under the child's bottom and behind his/her lower back. Feet should be kept flat on the floor or on a footrest (box or old directory). Their arms should be close to their body (not outstretched or reaching to the side), their elbows should be at a 90 degree or greater angle, and their wrists should be neutral (i.e. with their wrist at about the same level as their forearm). The wrists should not rest on the desk, wrist pad or armrests while typing or using a mouse. The top of monitor should be at eye level. Kids lack awareness of their body position when engrossed in an enjoyable activity, so it's important for adults to watch their posture and habits, correcting them when necessary.

Children should take a break from computer work every 20 minutes and spend no more than 45 minutes in any hour at a computer, and avoid spending more than 1-2 hours a day at computers and video games. Reminder software may be used to promote stretch breaks. Physical activity and exercise for about 60 minutes daily is essential. If the child frequently works from papers or a textbook, consider using a document holder. School curricula must include education on ergonomics.

Consult a specialist with known expertise in the management of RSI without delay if a child experiences pain or tingling in the neck, hands, arms, shoulders or back and if there are eye problems or headaches.

These health risks to children demand immediate action. But no one pushing the computerization agenda in our schools - neither IT companies, nor the government, nor school officials or parents - has yet publicly acknowledged the hazards, let alone taken action to remedy them.

Tip of the day: Consider placing the keyboard and mouse on a tray rather than on the tabletop

(The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI)

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Safety issues in Call Centres
Author: Dr Deepak Sharan
Bangalore, The Times of India, October 18, 2003

Cyber coolies or cyber cool, youngsters in Indian call centers are fast discovering that the bucks come at a heavy price to their health and well being. Turnover rates are estimated to be 22 per cent and rising, and over half of those who leave call centres actually shun the IT industry forever.

The problems of working in a call centre include:

Longer and unsociable hours leading to disruption of the body clock

Unreasonable targets and pressures from management and supervisors, including monitoring of average call duration and wrap-up time

Stipulated breaks are not made available, or - if they are -workers are 'encouraged' by the work culture to work on and not take them

Very tedious, repetitive work in a stressful environment with little chance to develop skills

Pockets of stale and dry air due to 24/7 use of ventilation, air filtering and heating systems

Exposure to sudden intense noise and to prolonged high levels of background noise

Larger screen monitors at cramped workstations

'Hot-desking' or sharing of desks leads to workers of different sizes using the same equipment without adjustment

Lack of regulation or guidelines on minimum ergonomic standards for Indian workplaces

(The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI)

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Some health issues in call centres
Author: Dr Deepak Sharan
Bangalore, The Times of India, November 1, 2003

Well-documented health problems in call centers include:

Musculoskeletal disorders, e.g., Repetitive Strain Injury (RSI). A Scottish study has shown that nearly two thirds of their staff suffers from pain in their hands, wrists or back.

Stress and job dissatisfaction. Three quarters of staff suffer from stress, with monitoring systems being the major cause.

Sleep disorders, behavioral and relationship problems

Nutritional disorders, e.g., obesity, malnutrition

Eyestrain

Dysphonia (inability to speak, pain, tension, croakiness, irritating cough, poor or no vocal power and breathing difficulties)

Hearing loss, burst eardrums, short-term memory loss, or acoustic shock (high-pitched ringing in ears or permanent tinnitus). One such worker in UK has already successfully sued British Telecom recently for 90,000 pounds.

Given the younger age profile of workers these health hazards could indicate long-term health problems and many of these illnesses could be permanent and progressive.

In general, the pressures of the work and the requirement to meet call-handling targets mean that Indian employers ignore health and safety issues, and prefer to highlight the lure of easy money for very little academic qualifications instead. Training of employees in safe ergonomic practices is the exception rather than the rule, and companies typically find a "fire and hire" policy more viable for employees with work related health disorders. Many Indian call centers claim to implement ergonomic standards handed to them by their overseas partners. While this is better than doing nothing at all, using western standards can lead to a serious mismatch because Indian workers are usually much smaller and shorter.

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A survival manual
Author: Dr Deepak Sharan
Bangalore, The Times of India, November 8, 2003

Request your HR manager for in-house training in ergonomics and healthy computing techniques specific to call centres. If you share your desk, readjust it before you log on. An ergonomic checklist on your screen may be followed before you start work. Adjust the listening level through your headsets at the beginning of each call. Break the opening greeting scripts into shorter segments, allowing you to rest your voice while callers respond to your questions. Take a rest break of at least 15 minutes every 2 hours. Leave your workstation during your break and do not browse the net or send emails! Take a micro break of 5 seconds every 5-10 minutes. Reminder software may be used to reinforce breaks and suggest appropriate stretches of neck and shoulders at the workstation. Learn to change posture often while sitting to release muscular tension. Drink plenty of water or caffeine-free soft drinks instead of tea or coffee. Ensure frequent small balanced meals, avoiding junk food. Catch up on your sleep during the day. Go in for meditation, massage or relaxation techniques and get your eyes and hearing tested every year.

Tip of the day: Do not ignore aches and pains or numbness and seek competent medical help before symptoms become permanent or severe.

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Call center ergonomics
Author: Dr Deepak Sharan
Bangalore, The Times of India, November 15, 2003

What can call centers do to hold on to their staff? The answer is simple: use ergonomics to address health and safety issues! Ergonomics principles should be applied to organisational procedures and policies; task design and training; workplace, workstation and equipment design, and selection and provision. This approach works only if: (i) there is an integrated systems approach rather than piecemeal application; (ii) an expert in ergonomics (with experience of Indian workplaces) is closely involved combined with participation of employees; and (iii) there is ongoing application through management and monitoring. The advantages include higher customer satisfaction from dealing with comfortable, alert call handlers; higher productivity; higher staff retention and morale; and lower costs and more flexibility associated with reconfiguring the facility to accommodate change and growth.

Indian employers tend to see work related disorders like RSI or stress as an individual, rather than a collective, problem that is an inevitable outcome of the work processes and organisation of call centre life. The emphasis should be on identifying the reasons behind the exodus of youngsters and improving work methods (e.g., moving from individual targets to team targets, and reduced pressure to limit call time), rather than trying to entice housewives and retired people in smaller towns. The result is predictable: an exodus of sick housewives and pensioners from call centres!

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What is RSI?
Author: Dr Deepak Sharan
Bangalore, The Times of India, November 22, 2003

Repetitive Strain Injury or RSI refers to a constellation of work-related disorders that is common in (but not exclusive to) computer users, due to diffuse involvement of muscle, fascia (covering layer of muscles), tendon and/or neurovascular structures, typically involving the neck and upper limb; though any part of the body (including back, legs, jaw, eyes and vocal chords) may be affected. It is also known as Occupational Overuse Syndrome (Scandinavia, New Zealand), Cumulative Trauma Disorder (USA), and Work Related Upper Limb Disorder (WHO).

RSI has probably been around for centuries, and musicians, butchers, checkout clerks, typists, hairdressers, assembly line workers, etc. have suffered RSI for ages (long before computers were invented)! The current epidemic of computer related RSI started in New South Wales, Australia 15-20 years ago. The Indian RSI epidemic probably started 5 years ago, although there is scant published data available.

Why should you bother about RSI?

15-25% computer users (both vocational and recreational) worldwide are estimated to have RSI. By this estimate nearly 6 million Indian computer users (out of an estimated total of 23 million) may be injured already. There is no other illness of this magnitude about which so little is known by any of the involved parties, i.e., the IT industry, individual computer users, furniture manufacturers and doctors.

My ongoing study on RSI in Bangalore since February 2001 has found that out of 1300 IT professionals, 75% were found to have at least one symptom of established RSI.

No one is immune to RSI. Any computer user, including pre-school children, who use the computer incorrectly for more than one hour daily, is at risk of RSI. The most productive and hard working employees are the most likely to get injured.

RSI can seriously disrupt work and domestic life. Injured workers can become unemployed and unemployable. This has already happened to 9 young IT professionals in India so far.

It is essential to raise public awareness about risks of RSI, to prevent the next generation of IT Professionals (i.e., today's children) from entering the industry while already injured. The computer furniture in schools is usually inappropriate, and worse, teachers and parents have no knowledge of ergonomics, RSI prevention and warning signs.

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Symptoms and stages of RSI
Author: Dr Deepak Sharan
Bangalore, The Times of India, December 1, 2003

What are the common symptoms?

Pain, burning, numbness, stiffness, tingling or “pins and needles” in the fingers, wrists, forearms, arms, shoulders, head, jaws, neck, back or legs

A constant need to stretch or massage one’s arms

Heaviness or weakness in hands or forearms

Visual strain or fatigue while working

Slow accumulation of injury occurs with gradual development of difficulty in day-to-day activities such as shaking hands, opening doors, driving, holding newspapers, using a comb, or holding a teacup

Stages of CRI

Stage Symptoms Usual duration of recovery (with appropriate treatment)

Stage 1 Pain during work that eases off as soon as you leave the job Recovery in days or weeks

Stage 2 Pain that goes home with you and interferes with daily activities, but disappears by the morning Recovery in months

Stage 3 Pain, tingling or numbness that wakes you up and stays with you all day and night Recovery in 6-24 months

The symptoms range from mild and diffuse aching to intense, searing, and very specific pain. The usual location of pain or discomfort at the onset is in the neck, upper back and shoulders. If neglected or treated inappropriately, it may lead to shooting pain, tingling or burning down the arm into the hands. At its worst, you may have difficulty in coordination or you may even be unable to use your hands. Generalised, diffuse RSI involving muscles virtually all over the body is not uncommon in Bangalore, even in children.

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Ergonomic risk factors for RSI
Author: Dr Deepak Sharan
Bangalore, The Times of India, December 6, 2003

Repetitive strain injuries (RSI) and other work related musculoskeletal disorders arise from ordinary arm and hand movements such as bending, straightening, gripping, holding, twisting, clenching and reaching. These common movements are not particularly harmful in the ordinary activities of daily life. What makes them hazardous in work situations is the continual repetition, e.g., typing on a keyboard, often in a forceful manner, and most of all, the speed of the movements and the lack of time for recovery between them. RSI’s are associated with work patterns that include combinations of:

Force, e.g., slapping the keys hard while typing.

Hazardous body positions: The commonest problem in India is hunching up of shoulders due to improper layout of the workstation, inappropriate equipment selection including chairs and lack of training regarding correct posture.

Static postures: To perform any controlled movement of the upper limb, the worker must stabilize the shoulder-neck region by contracting the muscles and keeping them contracted for the duration of the task. The contracted muscles squeeze the blood vessels and do not allow drainage of metabolic waste products from the muscles leading to tissue damage. The neck-shoulder muscles become fatigued and sore, even though there is no movement. At the same time, the reduced blood supply to the remaining parts of t

Continual repetition of movements

Compression of small parts of the body against a hard surface, e.g., resting the wrist on the table or propping the elbows on armrests while typing

A pace of work that does not allow sufficient recovery between movements

Temperature: too cold or hot and humid.

Vibration, e.g., use of vibrating tools.

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Psychosocial risk factors for RSI
Author: Dr Deepak Sharan
Bangalore, The Times of India, December 13, 2003

When the epidemic of Repetitive Strain Injuries (RSI) first appeared in Australia and other developed countries, there was a popular line of thought that it was a psychosomatic disorder and there was nothing wrong structurally with the workers bodies. Many doctors refused to treat RSI claiming it was a fictitious condition brought about by greed for financial compensation. The grim RSI statistics in India mock such attitudes since there are no workers compensation laws here and workers typically hide/ignore their injury till it becomes impossible to work any longer. Subsequent research has led experts to look to the work environment for the primary causation of RSI. Physical (or ergonomic), psychosocial and work organizational risk factors act in concert to produce these disorders. Unfortunately, some medical professionals still consider that RSI’s are “all in

Commonly identified psychosocial stressors include:

Low levels of social support at work

Lack of supervisory support

High perceived work stress

Fear of technology, e.g., fear of not having adequate skills

Financial aspects: pay structure, perks, etc.

Societal aspects: status, prestige of job, etc.

Job security: likelihood of holding on to a job and likelihood of finding another similar or better job in the event of retrenchment (“pink slip syndrome”). Research has identified this as one of the most potent job stressors.

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Work organisational risk factors for RSI
Author: Dr Deepak Sharan
Bangalore, The Times of India, December 20, 2003

The way work is organized can increase a worker’s risk of having a work-related musculoskeletal disorder. The common risk factors are:

Inadequate work-recovery cycles (insufficient opportunities for muscle recovery or alternative tasks)

Temporal profile of job design: long hours, night shifts, excessive pace of work, deadlines, etc.

Job content: variety, repetitiveness, monotony, skill use, mental workload, clarity of demands, participation in decision-making, etc.

Low levels of worker control over pace and variety of work

Lack of participation in task design

Performance monitoring

Interpersonal relations: group cohesion, support from co-workers and supervisors, availability of feedback, etc.

Organisational aspects: structure of organisation, bureaucratic characteristics, etc.

Physical aspects of the work environment and work tasks, such as noise, poor lighting, inadequate ventilation, that increase psychological demands on the worker

Poorly designed working conditions therefore place a stress load on workers both physiologically and psychologically. When people feel stressed the muscles also tense up. Excessive force may then be used to complete a task, or the movement may be jerky rather than smooth and controlled.
Early signs and symptoms may include:

Localised fatigue, discomfort or pain

Headaches

Work related tension or stress

Low job satisfaction

Boredom or monotony

Stress related illnesses, e.g., heart disease or absenteeism

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Physical office factors
Author: Dr Deepak Sharan
Bangalore, The Times of India, January 10, 2004
Physical factors in the office include lighting, temperature, noise, radiation and vibration. Typical symptoms of problems related to each are:

Lighting

Difficulty seeing information

Eyestrain (burning, red, watery or blurry eyes)

Headaches

Disturbance from flickering lights or excessive light

Neck pain (due to craning the neck forward to see clearly)

Temperature control

Too warm or too cold or unequal distribution of heat (e.g., between the feet and the head)

Humid (stuffy, sticky)

Stale air due to lack of air flow

Dryness

Noise, e.g., people talking loudly, printer or fax

Inability to communicate effectively

Annoyance or distraction and interference with tasks (drop in performance, e.g., short term memory and attention)

Stress

Lack of privacy

Electromagnetic fields

Static electricity or shocks

Eye problems

Vibration

Decrease in visual acuity

Poor performance (speed and accuracy) with input devices like keyboard and mouse

Stress

The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI

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How does RSI occur?
Author: Dr Deepak Sharan
Bangalore, The Times of India, January 17, 2004

Repetitive Strain Injury (RSI) and other work related musculoskeletal disorders (WMSDs) do not happen as a result of a single accident or injury. Rather, they develop gradually as a result of repeated trauma to muscles, tendons or nerves, causing tissue inflammation.

Muscle Injury

When muscles contract, they use chemical energy from sugars and produce by-products such as lactic acid, which are removed by the venous blood. A muscle contraction that lasts a long time reduces the blood flow leading to depletion of nutrients as well as accumulation of irritant chemicals. The severity of the pain depends on the duration of the muscle contractions and the amount of time between activities for the muscles to get rid of the chemicals.

Tendon Injury

Tendons consist of numerous bundles of fibres that attach muscles to bones. The tendons of the hand and wrist are enclosed in sheaths through which the tendon slides. The inner walls of the sheaths produce a slippery fluid to lubricate the tendon. With repetitive or excessive movement of the hand, the sheath may not produce enough fluid, or it may produce a fluid with poor lubricating qualities. This creates friction between the tendon and its sheath, causing inflammation and swelling of the tendon area. Repeated episodes of inflammation cause fibrous tissue to form. The fibrous tissue thickens the tendon sheath, and hinders tendon movement. Inflammation of the tendon sheath is known as tenosynovitis.

Tendons without sheaths, generally found around the shoulder, elbow, and forearm, when exposed to repetitive trauma are vulnerable to micro-tears. The tendon becomes thickened and bumpy, causing inflammation (tendonitis).

Nerve Injury

With repetitive movements and awkward postures, the tissues surrounding nerves (e.g., muscles, tendons) become swollen or stiff, and squeeze or compress nerves. Compression of a nerve causes muscle weakness, sensations of "pins and needles", numbness, dryness of skin, and poor circulation to the extremities.

The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI

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Tackling myofascial pain
Author: Dr Deepak Sharan
Bangalore, The Times of India, January 23, 2004

Myofascial trigger points are tiny knots that develop in a muscle when it is injured or overworked. The typical symptom of a trigger point is referred pain; that is, trigger points usually send their pain to some other site. This is the reason conventional treatment of pain so often fails. It's a mistake to assume that the problem is at the place that hurts! For instance, pain in the wrist is often due to trigger points in the neck, and pain in the lower back is frequently due to trigger points in the groin. Studies have shown that trigger points are the primary cause of pain up to 85% of the time and are at least a part of nearly every pain problem, yet very few Indian doctors and physiotherapists are familiar with trigger points, perhaps because it is not taught in our medical universities and is not usually mentioned in medical textbooks.

Trigger points cause headaches, neck and jaw pain, low back pain, calf pain, heel pain and symptoms similar to tennis elbow, carpal tunnel syndrome and slipped disc. They are the source of the pain in such joints as the shoulder, wrist, hip, knee and ankle that is so often mistaken for spondylitis, arthritis, tendinitis, bursitis, or ligament injury. Trigger points also cause symptoms as diverse as dizziness, earaches, nausea, heartburn, false heart pain, heart arrhythmia, genital pain and numbness in the hands and feet. The challenge is to find those trigger points and treat them successfully.

Luckily, the pain and other symptoms (e.g., tingling, burning, numbness, etc.) caused by trigger points occur in extremely predictable patterns. When you know where to look, trigger points are easily located and deactivated. The late Dr. Janet Travell, M.D., personal physician to Presidents Kennedy and Johnson, is credited with the development of the technique of trigger point therapy. This has rapidly grown to become one of the most potent treatment modalities available for myofascial pain. Interestingly, it is considered a part of mainstream medicine in the west and not an alternative modality.

The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI

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Beware of thoracic outlet syndrome
Author: Dr Deepak Sharan
Bangalore, The Times of India, January 30, 2004

The thoracic outlet is an area in front of your chest, between your neck and shoulder where the nerves and blood vessels pass through the rib cage and muscle layers on their way towards the arm. This roughly triangular passage is increasingly implicated in computer related RSI (repetitive strain injury) and only recently getting the attention it deserves as a frequent source of neck and upper limb pain even in non-computer users.

There are several non-RSI causes of thoracic outlet syndrome (TOS), including an extra rib (cervical rib), over-development of the neck muscles (such as in weight lifters), carrying heavy loads (e.g., backpacks), and posture abnormalities. In computer related RSI, it is caused by the forward head posture, drooping shoulders, muscle weakness or tightness, and working on high tabletops leading to constant muscle tension in the shoulder girdle. Myofascial trigger points develop in the scalene muscles in the neck, which keeps the first rib pulled up against the collarbone, leading to pinching of the nerves and blood vessels.

The character and pattern of symptoms will vary depending on the degree to which the nerves and/or blood vessels are compressed. The patient may complain of tingling, numbness, weakness and discomfort particularly down the inside of the arm going into the hand. There may also be swelling, paleness and coldness of the arm and hand, and bluish discolouration of the fingertips in extreme cases. Other related symptoms may include headaches in the back of the head and pain in the neck, shoulder and arm. Symptoms can be brought on by overhead activities such as hair combing, or at night when sleeping on one side (especially with the elbows tucked in under the body or the pillow) which can put pressure on the structures within the thoracic outlet.

We have found TOS to be the second commonest cause of computer related RSI in India (after myofascial trigger point syndrome) and this condition is also extremely common in the general population, including housewives and students.

The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI. Email: deepak@deepaksharan.com

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Demystifying neck and back pain
Author: Dr Deepak Sharan
Bangalore, The Times of India, February 7, 2004

In this country, pain and stiffness in the neck, upper back and shoulder, associated with giddiness or pain shooting down the arms is almost invariably labeled as spondylitis or spondylosis. The term Cervical Spondylosis refers to degenerative changes (a “wear and tear” phenomenon) noted on x-rays, in the discs that separate the vertebrae of the spinal column and the facet joints.

The typical symptoms of Cervical Spondylosis are a dull ache or stiffness in the neck, sometimes associated with radiating pain down the arms or shoulder blades. The pain is rarely severe and if described as such or if significant analgesia (pain killers) is required, other diagnoses like myofascial pain or Thoracic Outlet Syndrome must be considered. Cervical Spondylosis causes a significant problem only when there is pinching of the nerves by a large herniated disc or compression of the spinal cord or vertebral artery by the worn out vertebrae.

Although neck pain is an extremely common symptom, affecting 15% of males and 22% of females, Cervical Spondylosis is rarely the main culprit. The reason for this is that after the age of 30 the human spine practically always shows changes of degeneration. Numerous studies have been done where people were picked at random for x-rays or MRI scans. Degenerative changes or disc bulges in cervical spine were seen in up to 40% of the adult population and its frequency reached 90% by the age of 60. Yet most of these subjects were not in pain! Autopsy studies have shown degenerative changes in 60% of females and 80% of males by 49 years.

Degenerative changes in the cervical spine are so prevalent that the mere presence of such abnormalities cannot be taken as prima facie evidence of the causality of pain. If you took a random sample of middle-aged workers in any of our offices, and performed screening x-rays or MRI scans, the majority would have reportable “abnormalities”. If you are an adult and based on a neck x-ray, CT or MRI scan, have been reported as having spondylitis or a disc bulge, you are probably normal for your age. Your x-ray may be suffering from spondylitis but the true source of your pain may lie elsewhere!

The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI. Email: deepak@deepaksharan.com

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Take care of your posture
Author: Dr Deepak Sharan
Bangalore, The Times of India, February 14th, 2004

Posture is essentially the position of the body in space. Optimal posture is the state of muscular and skeletal balance that protects the supporting structures of the body against injury or progressive deformity, whether at work or rest. Correct posture involves the positioning of the joints to provide minimum stress on the joints of the body. Conversely, faulty posture increases stress on the joints. Strong muscles can compensate for this increased stress, but if they are weak or the joints lack mobility or are too mobile joint wear and modification can occur. Poor posture may cause fatigue, muscular strain, compression of blood vessels and pain. In addition, faulty posture can affect the position and function of major organs.

If poor posture is a factor, then posture training may help relieve your back pain. During posture training, you will be taught healthier ways to sit, stand, sleep and lift objects.

Proper posture occurs when:

1. The shoulders are held back and down

2. Upper back (Thoracic spine) curves forward only slightly

3. Shoulder blades (scapulae) do not "wing out"- they should lie flat on the chest wall

4. The chest curves out - forward tips of the shoulders would not touch a yardstick placed across the upper chest

5. The collar bones are level or slope only slightly upwards

6. From the front, the chin is at least 2 inches, if not 3 or 4 inches, above the notch in the sternum (breast bone).

Nature has aligned us so our center of gravity falls through our body and moves through specific bony landmarks: Earlobe over the middle of the shoulders, over the hip joint, and over a point about an inch in front of the ankle joint. Correct postural alignment, then, is basically the ears over the shoulders over the hips, with the head up and the shoulders back. With correct muscle flexibilities and strength balances, proper posture can and will be maintained without conscious effort at all times, even while standing relaxed. This point is important from a physical performance standpoint, because when you are fatigued or working under stress, you tend to revert to your relaxed posture and alignment. If this relaxed posture is not straight and efficient, you will fatigue even more quickly and perform less efficiently.

The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI. Email: deepak@deepaksharan.com

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Work shouldn’t hurt
Author: Dr Deepak Sharan
Bangalore, The Times of India, February 21st, 2004

The International RSI (Repetitive Strain Injury) Awareness Week will be celebrated from February 23rd, culminating on February 29th (RSI Day). Throughout the week, attention will be focused on the injuries that are affecting an increasing number of people in our workplaces and communities. Preliminary results of our on-going study among over 1600 Indian IT professionals (2001-2004) suggest that over 75% reported classic RSI symptoms. Despite their prevalence in India, workers, employers, and medical professionals poorly understand these disorders.

RSI is an umbrella term for a number of overuse injuries affecting the soft tissues (muscles, tendons, and nerves) of the neck, upper and lower back, chest, shoulders, arms and hands. Typically arising as aches and pains or numbness, these injuries can progress to become crippling disorders that prevent sufferers from working or leading normal lives.

The main purpose of RSI Day is to raise public awareness about RSI, to prevent others from being injured and to promote understanding and acceptance for those with RSI. Another goal is to encourage workers not to ignore aches and pains, especially in the neck and shoulders and to seek early, competent medical intervention before permanent structural damage occurs. A popular misconception is that RSI’s are lifestyle disorders that are a part of every computer operator’s working life. Unfortunately, these disorders are always progressive and do not get better just by resting, changing hands (e.g., using the left hand for the mouse) or taking medicines. Treatment is extremely specialized and employs physical modalities to reverse existing tissue injury/inflammation and/or tethering of nerves. RSI disability is preventable by learning “healthy computing” techniques and by adaptations in seating, lighting, and other working conditions.

Another goal is to educate the establishment. Most Indian employers, government offices, banks, and schools are inclined to shrug off RSIs or to deny the obvious causes of the problem, either because of ignorance or because of unwillingness to get involved. Our IT industry’s attitude to RSI currently is like that of an ostrich: it refuses to confront the problem hoping the danger will eventually pass. Most companies take no significant preventive measures, preferring to wait till employees develop debilitating pain and inability to work. Worse, RSI’s are usually misdiagnosed as spondylitis, slipped disc, arthritis or carpal tunnel syndrome and hence treated inappropriately, adding to the incapacitation.

The public generally assumes RSI comes only from computers. This is one of the myths we are trying to overcome. RSI doesn't discriminate; it hits a cross section of the population engaged in a variety of occupations (e.g., manufacturing sector, check out clerks, teachers, etc) and does not spare even children and housewives.

The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI. Email: deepak@deepaksharan.com

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Tomorrow is RSI Day
Author: Dr Deepak Sharan
Bangalore, The Times of India, February 28th, 2004

The International RSI (Repetitive Strain Injuries) Awareness Day is observed annually on the last day of February, the only day that the calendar takes a break from repetitiveness. In Bangalore, we have conducted poster exhibitions, RSI Quiz, open house, press meets and awareness lectures on RSI prevention, every year since 2001.

Since there are very few trained and qualified professionals or researchers working in this field, reliable data on RSI is hard to come by. There are an estimated 25 million computer users in India and the number of them already suffering from RSI would be mind-boggling. The paucity of a large volume of data prevents IT organizations, other employers, NASSCOM and furniture manufacturers acknowledging the enormity of the problem and establishing some basic industry standards in Ergonomics. Our initiative this year is to collect more data on RSI, assess the predisposition of individual computer users to RSI and use this data to campaign forcefully for healthier offices.

Starting tomorrow, for a period of one month, all computer users (including occasional users and call center staff) are encouraged to fill out a confidential online RSI questionnaire on my website (www.deepaksharan.com). All respondents will get feedback regarding their predisposition, suggestions regarding remedial measures and an attractive poster on RSI Prevention that can be put up at your workstation. In addition, we would be offering 10 copies of the most popular Stretch Break software (costing $50 each), and 10 touch-typing tutorials by Mr. Arun Kumar, to encourage participation in the survey. There will also be a prize quiz on RSI awareness.

Actions you can take on this occasion:

· Participate in the online survey and quiz and send an e-mail to everyone in your organization and to as many Indian computer users as possible, motivating them to participate.

· Read about the RSI epidemic in India from the Internet and educate your family, friends and colleagues. Reading this particular column regularly would be a good start!

· Join the RSI India Patient Support Group (run by Indian RSI patients) by sending an email to rsi-india-subscribe@yahoogroups.com

· Ask your HR Manager to organize training workshops in Healthy Computing and have your workstation assessed. Remember, these techniques have to be formally learned from experts and only a tiny minority of Indian computer users is trained in using the computer safely. If your company chooses not to do this you should take the initiative to arrange this program for a group of colleagues.

RSI Day may come and go, but vigorous efforts to prevent this pernicious disease must continue throughout the year if we are to reduce the number of youngsters forced out of jobs because of RSI.

The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI. Email: deepak@deepaksharan.com

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Why do people work in pain?
Author: Dr Deepak Sharan
Bangalore, The Times of India, March 6th, 2004

Indian IT employers tend to see Repetitive Strain Injuries (RSI) as an individual, rather than a collective problem to which all employees are susceptible. They argue that if the ergonomics of their offices is incorrect and everyone does the same type of work, why is it that all employees do not complain of pain and a minority is unable to work at all. There clearly is a discrepancy here because statistics point to 3 out of 4 Indian computer users, in all type of IT organizations, whether employing 25 or 5000 people, whether Indian or Multinational, who report musculoskeletal symptoms in confidential surveys.

The answer may lie in individual differences in:

· Knowledge of safe and healthy computing techniques

· Flexibility and strength of neck and shoulder muscles

· Body awareness (ability to perceive discomfort due to abnormal postures)

· Anatomical factors, e.g., cervical ribs

· Ability to pace one’s work

· Ability to manage stress

Also RSI appears in different stages of increasing severity, and employees in the earlier stages tend to attribute it to work stress, sleeping posture, exercises in a gym, or minor injuries. Typically, if pain appears in the right hand, the left hand is used for typing, eventually leading to a situation when neither hand can be used. Symptoms are usually reported at a stage when they cannot sit or type any longer.

It is our experience that many Indian IT professionals are reluctant to admit having RSI for fear of retrenchment and feel uncomfortable or embarrassed asking for ergonomic modifications to their workstations. Many fear being labeled “sissy” by their colleagues, “psychotic” by some medical professionals, or “unemployable” by the industry. A popular misconception is that muscle related disorders cannot be cured and hence there is no point in complaining about it, putting your existing job at risk.

Many continue working in pain because of personal ethics, loyalty to employer and colleagues, impending deadlines, financial benefits, inability to get time off to see a medical specialist, eagerness to impress superiors by heroics, or sheer apathy in the hope things will get better with time.

Indian computer users typically underestimate the seriousness of RSI and need to be more proactive in seeking safer workplaces. After all, IT’s your health.

The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI. Email: deepak@deepaksharan.com

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Why is sitting such a pain?
Author: Dr Deepak Sharan
Bangalore, The Times of India, May 22nd, 2004

Sitting jobs require less muscular effort, but that does not exempt people in desk jobs from the injury risks usually associated with more physically demanding tasks, e.g., that of a construction worker or a sportsperson. Various studies have shown that 25-75% of clerks, assembly-line workers, and data entry operators suffer from back or neck pain. Varicose veins, stiff necks, swelling and numbness in the legs are also more common among seated employees than among those doing manual tasks. Mother Nature did not design the human spine to sit. Sitting, and especially prolonged sitting, is a lot tougher on your back than lying down, standing up, and even lifting (assuming that you are lifting correctly). Sitting puts enormous strain on the lumbar discs (a cushion between the back bones) of the lower back. Sitting up straight is a little better, but if we lean forward when we sit, the pressure on the disc shoots up. When we lean back in our chairs this pressure is reduced. Most of us arch our backs without even realizing that this is a natural way of getting some relief. If you stand sideways and look in a mirror, you'll see that your lower back has a natural curve, called a lordotic curve. It's crucial to maintain normal lordosis, because in this position, the structures that support the spine - the muscles, ligaments, and discs can work in perfect harmony. If your back is not supported while sitting, your back muscles will get tired very quickly and you slouch forward in an attempt to relax those muscles. The problem is that slouching, though it feels divine, reduces the natural lumbar curve and gradually overstretches spinal ligaments. Slouching also causes a steady compression on the discs that hinders their nutrition and can contribute to their premature degeneration. Sitting requires the muscles to hold the trunk, neck and shoulders in a fixed position, which squeezes the blood vessels in the muscles reducing the blood supply to the working muscles just when they need it the most. An inadequate blood supply accelerates fatigue and makes the muscles prone to injury. Also, it takes more muscular effort to move your neck, shoulders, and back while sitting. Is there a way out? Learn more next week.

The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI. Email: deepak@deepaksharan.com

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How to sit properly
Author: Dr Deepak Sharan
Bangalore, The Times of India, May 29th, 2004

While it's all very well to pontificate that prolonged periods of sitting are best avoided, for many, it is inescapable. What aspect of working in a sitting position is responsible its ill effects?

A biomechanically incorrect body position is largely responsible for the adverse effects of prolonged sitting.

Poor body positions can also originate from an unsuitable job design that requires employees to sit continuously for longer than one hour.

The duration of sitting, along with the shape of the body in a sitting position, is the most critical risk factor in work in a sitting position.

A poorly designed or improperly selected chair will resist all attempts to achieve proper posture.

An unsuitable workspace that prevents employees from sitting in a balanced position can cause poor body positions. The workstation may be unsuitable because the chairs are too high or low with respect to the table height for an employee's body size and shape.

Improper or inadequate training can also lead to inappropriate body positions. Employees may be unaware of the health hazards of sitting jobs because they are not as apparent as those of physically strenuous tasks. As a result, employees may not know which work practices to avoid and which ones to adopt.

For each major joint such as the hips, knees, shoulders, elbows, and wrists, there are ranges within which every healthy person can find comfortable positions. These positions should not interfere with a person's breathing or blood circulation, impede muscular actions or hinder the normal functions of the internal organs. Varying these positions frequently is the essence of healthy sitting work. Hence, a good sitting position is one that allows employees to change their body positions frequently and effortlessly when they want without being restricted by the workstation or job design. Next week: How is balanced sitting posture achieved?

The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI. Email: deepak@deepaksharan.com

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Balanced sitting posture
Author: Dr Deepak Sharan
Bangalore, The Times of India, June 5th, 2004

Aim to maintain a balanced or neutral posture irrespective of where you are sitting and for what purpose. Becoming aware of your body position is much more important and effective than relying on your furniture to do it for you. Head and Back: · Your head is centered over the shoulders, and not dropped forwards · Your ear, shoulder and hip are in a straight line when seen from the side · Your chin is relaxed and tucked in, not dropped down or pushed forward · Your rib cage is lifted up and curved out - forward tips of the shoulders should not touch a yardstick placed across the upper chest · Shoulder blades (scapulae) do not "wing out"- they should lie flat on the chest wall · Your spine keeps its natural curves at the neck, mid-back and low back Upper Limbs: · Your shoulders are relaxed and pushed back slightly, not rounded or curved forward · Your elbows are placed loosely to the sides, just touching the chest, and vertically below the shoulders · Your forearms are parallel to the floor or preferably extend slightly downward (around 100 degrees at the elbow) · Your wrists are flat or neutral, not extended up or down · Your hands and fingers are relaxed and gently curled downwards Lower Extremities: · Your pelvis is rotated forward so that you actually sit on the lower bones of the pelvis (ischial tuberosities), and not on the tailbone · Your thigh - torso angle is open to 110 to 130 degrees and knees placed slightly lower than the hips · Your feet are flat, parallel to the floor and firmly placed on the floor or on a footrest (if your legs dangle up in air) Tip of the day: Recruit your workplace neighbour as your posture consultant. Ask him or her to let you know when you slouch. Do this for each other till maintaining good posture becomes a habit.

The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI. Email: deepak@deepaksharan.com

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Reflex Sympathetic Dystrophy
Author: Dr Deepak Sharan
Bangalore, The Times of India, June 12th, 2004

P. was a young, high-flying software pro 2 years ago, when he developed burning pain in his arms and hands, numbness, increased skin sensitivity, cold, botchy pale skin discolouration, muscle atrophy, swelling and stiffness in multiple joints. His hands became wooden and virtually useless. After receiving empirical treatment for arthritis without relief, he was diagnosed as Thoracic Outlet Syndrome with Reflex Sympathetic Dystrophy (RSD). RSD (also called complex regional pain syndrome) is a chronic pain condition due to disturbance in the sympathetic (unconscious) nervous system that controls the blood flow and sweat glands in the limbs. Often an injury or surgery can cause RSD. Other causes include nerve compression, infection, cancer, neck disorders, stroke, or heart attack. Sometimes the cause of RSD is unknown. The key symptom is continuous, intense pain out of proportion to the severity of the injury, which gets progressively worse over time. Often the pain spreads to include the entire arm or leg, and may lead to depression or anxiety, which heighten the perception of pain and make rehabilitation efforts more difficult. Like other RSI's, RSD is diagnosed primarily by physical examination. But because many other conditions have similar symptoms, it can be difficult to make a firm diagnosis of RSD early in the course of the disorder when symptoms are vague or mild. Physical therapy is important to regain function and reduce discomfort. Successful treatment depends upon the patient's full and active participation in therapy. After appropriate physical therapy, P. is now virtually symptom free and back to full time computing with an IT major at Bangalore. Many different medicines have been tried for RSD, including local anaesthetics, antiseizure drugs, antidepressants, etc. Other techniques include sympathetic nerve blocks, surgical sympathectomy (a technique that destroys the nerves), spinal cord stimulation or intrathecal drug pumps (devices to administer drugs directly to the spinal fluid). However, no single modality has produced consistent long-lasting cure.

The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI. Email: deepak@deepaksharan.com

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Backpacks cause bad backs
Author: Dr Deepak Sharan
Bangalore, The Times of India, June 26th, 2004

Did you know that over 50 per cent of schoolchildren in Chennai were found to be in chronic pain due to carrying heavy backpacks? At the start of each fresh academic session, it is customary to express concern in the print media about the plight of our over-burdened children. There was an unsuccessful attempt at seeking legal intervention last year. Unfortunately, the matter tends to rest there and nothing changes, except in a handful of enterprising and empathetic schools. So, what does carrying backpacks actually do? · Total weight on the body increases · The direction and magnitude of the resultant force changes. The body usually leans forward. · The body's center of gravity changes affecting stability · A healthy body compensates for this change to maintain stability. Commonly, the head is raised up to prevent falling forward. · If the body's adjusting capacity is exceeded, health is affected Depending on the magnitude, direction, frequency and duration of the external forces due to backpacks, one or more of the following may happen either instantaneously or over time: · Tiredness or muscle fatigue · Swelling · Pain in the head, neck, back, shoulders, arms or hands · Muscle spasms or stiffness · Tingling or numbness · Curved or rounded back · Altered gait The immediate result of carrying too much unbalanced weight for too long is muscle soreness and strained ligaments. Researchers have found that backpacks lead to restricted movement of the spine and alter the fluid content of discs, making the child a prime candidate for permanent structural damage such as herniated ("slipped") disc and degenerative arthritis of spine later in life. Next week: Solutions

The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI. Email: deepak@deepaksharan.com

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How to choose a backpack
Author: Dr Deepak Sharan
Bangalore, The Times of India, June 26th, 2004

When you go to buy a new backpack, take the books and articles that you usually carry to school. Try on the backpacks with the typical weight that you usually carry, so that you will know for sure how it feels and if all the articles fit in. These are the ergonomic design features to look for: 1. 2 contoured (curved) shoulder straps to allow your arms to move freely as you walk and to disperse the weight of your backpack across both shoulders. 2. Padded back. 3. Multiple compartments for better weight distribution. 4. Hip and chest straps to transfer the weight from your shoulders to your torso and hips, and to stabilise the backpack. 5. Compression straps to secure and stabilise the articles in the backpack, and bring the weight/contents in the backpack closer to the back. 6. Reflective stripping for visibility at night. 7. Resist the temptation to buy a bigger backpack than what you need because you may end up carrying more than you really need to! The backpack should not be wider or longer than your torso. (The torso extends from the bony bump at the base of the neck down to the top of the hips.) 8. Lightweight backpack - The backpack itself should not add much weight to the load. Some students in Bangalore have started using backpacks on rollers. This may be impractical in most cases, due to uneven and difficult terrain (footpaths, buses, stairs, or overcrowded hallways). There are also concerns about possible long-term wrist injury if you have to carry it frequently because such backpacks are heavier than usual. Currently the Indian backpack manufacturing industry is fashion focused and has ignored the many consumer and professional concerns regarding the ergonomics of packs. The better-designed backpacks are usually exorbitantly priced and beyond the reach of most parents. Next week: more tips to reduce backpack injuries

The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and an expert on RSI. Email: deepak@deepaksharan.com

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The art of carryng backpacks
Author: Dr Deepak Sharan
Bangalore, The Times of India, July 3rd, 2004

Here are tips to wear the backpack correctly:

- Pack sensibly and leave non-essential items behind. Organise articles in the backpack so that the heaviest items are closest to your back. Lighter articles, like lunch or clothing can be placed on top of books or in compartments further away from the back. Organise the backpack to use all of its compartments.

- Anything that could poke through the pack's material, such as scissors, should be stored in a protective container. Do not let straps or items hang loosely from the back of the backpack.

- While lifting the backpack, face the pack, bend at the knees, use both hands, and check the weight of the pack. Lift the backpack with your legs, not your back. Apply one shoulder strap and then the other. Do not swing the backpack to put it on or to take it off. Do not bend over at the waist when wearing or lifting a heavy backpack. - While carrying the pack, walk normally, with the shoulders down and back and the stomach muscles tightened.

- Never carry the backpack on one shoulder; because you may end up leaning to one side to compensate for the extra weight, leading to pain. In addition, narrow straps that dig into the shoulders can interfere with circulation and the nervous system, leading to tingling, swelling and weakness in your arms and hands.

- The backpack should be evenly centered in the middle of your back, between the bottom of the neck and the curve of the low back, so that the largest, strongest back muscles are used. The straps should be snug but not excessively tight, and should hold the pack about two inches above the waist. Straps that are too tight can cause the pack to ride up on the neck. - Readjust the straps every time you use the backpack.

- Clean out the backpack at the end of each day and take out any unnecessary items.

The writer is HOD, Pediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI. Email: deepak@deepaksharan.com

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The school's role in backpack safety
Author: Dr Deepak Sharan
Bangalore, The Times of India, July 10th, 2004

The majority of schools in India refuse to get involved in activities designed to prevent spinal injuries in students due to overloaded backpacks, citing paucity of funds for lockers. Here are some suggestions regarding what they can do:

- Provision of storage space under the benches in classrooms. An example is a metallic lockable basket introduced by Delhi Public School, Bangalore.

- If space and finance is not an issue, lockers can be provided within or outside classrooms. Students should be given enough time between classes to return to lockers.

- Provision of safe drinking water and hygienic food in the school canteen, and discouraging students from carrying their tiffin carriers and water bottles.

- Class sets of textbooks can be shared by small groups of students. Photocopying pages from textbooks for use in classrooms is another option.

- Teachers should make greater use of overheads and/or slides, and encourage group activities/discussion.

- Using worksheets and folders for homework, leaving notebooks in school.

- The books can be published in separate volumes, thereby decreasing the thickness of the book. This way the student can also take only the volume that is necessary for that particular day of class.

- Only paperback books should be ordered.

- Purchasing books on CD-ROM or putting some curriculum over the Internet, if resources permit.

- While preparing timetables at the start of academic session, teachers should give some thought to allotting subjects considering their physical "load", among other factors.

- Staggered homework schedules, so that students do not turn power-lifters on certain days of the week.

- There should be different bags for different activities. For example, one should carry a separate bag for athletics, music or swimming- there's no use in carrying a tennis racquet to history class. The separate bag should remain in safe storage until it needs to be used.

- School authorities should implement education programmes about use of backpacks in a safe, and biomechanically correct way and correct posture. This educational activity should be supported and endorsed by parents, teachers and school administrators.

(The writer is HOD, Paediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI. Email: deepak@deepaksharan.com)

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Sharing the child's burden
Author: Dr Deepak Sharan
Bangalore, The Times of India, July 17th, 2004

Here are some suggestions for parents to tackle problems arising out of overloaded backpacks in school children:

- Involving other parents and your child's school in solving the backpack burden might be beneficial. Team up with other parents to encourage implementable, affordable and practical changes.

- While preparing timetables at the start of academic session, parents can work with teachers to give some thought to allotting subjects considering their physical "load", among other factors.

- Encourage your child to tell you about pain or discomfort that may be caused by a heavy backpack. Do not ignore any back or neck pain in a child or teenager. Consult a paediatric orthopaedist for advice regarding treatment and strengthening exercises for the lower back and abdominal muscles.

- Encourage your child to participate in outdoor sports, swimming or yoga.

- Consider buying a second set of textbooks for your child to keep at home.

- Nightly inspections (and repacking if necessary) of backpacks.

No matter how well designed the backpack, children need to keep the backpack loads reasonable (usually about 10% of total body weight). A bathroom scale can be used to get an idea what 10% of body weight feels like. Newer research indicates that even 10% may be too heavy for some children because children differ in height, body mass index, muscular strength, ability to perceive pain, etc.

The series of articles on backpack safety will conclude next week.

(The writer is HOD, Paediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI. Email: deepak@deepaksharan.com)

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Beating the backpack blues
Author: Dr Deepak Sharan
Bangalore, The Times of India, July 24th, 2004

There are many who are skeptical about the physical damage overloaded backpacks can cause to growing children and teenagers. Let us do a bit of "heavy" math. An average Bangalore schoolkid's backpack probably weighs about 10 kg. If the child lifts the backpack 10 times per day for 200 days per school year, the weight lifted totals 20,000 kg (or the equivalent of 30 maruti cars)! It is no wonder so many students look like the leaning tower of Pisa these days.

Here are five signs to help you recognise an overloaded backpack:

A struggle to get the backpack on or off

Pain when wearing the backpack

Tingling, burning or numbness in the back, shoulders or arms

Red marks or swelling, especially around the shoulders

Changes in posture, e.g., bending forward while carrying backpack, arching the back, or leaning to one side

Over the past 5 weeks, we have made several practical suggestions for children, parents, school administrators and teachers through this column. Of course, no solution is perfect for everyone. If you think any of these ideas may work for your school, be a crusader for the child's back! If your school has come up with a novel solution, share it with others.

In an attempt to involve more medical professionals to tackle this serious problem, we have launched a nationwide study to estimate the extent of health problems arising out of heavy backpacks. Initially, the study will commence at Bangalore and Cochin (through Indian Academy of Pediatrics).

We invite parents and schools that wish to contribute to finding solutions to the backpack menace to participate in this study. The survey forms can be filled online on www.deepaksharan.com/pocs_backpack.html or collected from Bangalore Children's Hospital (Phone: 23342035, 28600712) or The Apollo Clinic (56973328-31, 25633833). There are several prizes (backpacks, what else) on offer to encourage participation. Every respondent will get a brochure on Backpack Safety. We have also set up an online discussion group called Backpack Safety Forum for all interested parents, children, school administrators, teachers, medical professionals and backpack manufacturers.

(The writer is HOD, Paediatric Orthopaedics & Rehabilitation, Bangalore Children's Hospital, and a leading expert on RSI. Email: deepak@deepaksharan.com)

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Understanding double crush syndrome
Author: Dr Deepak Sharan
Bangalore, The Times of India, July 31st, 2004

In the last 5 years, the medical literature has repeatedly documented the involvement of multiple injury sites in repetitive strain injuries (RSI). "Double Crush" Syndrome refers to chronic, mild compression at multiple levels along the course of the nerve.

Overuse or repetitive activities in computer users keep the nerve in positions that result in increased pressure around the nerve for prolonged periods of time. These individuals can quickly accumulate enough pressure points to produce symptomatic nerve entrapment. An example is resting your bent elbows on an unpadded armrest while typing leading to damage to the ulnar nerve. The typical symptoms are tingling, burning pain or numbness on the inner side of the forearm and little and ring fingers.

If the job involves a significant amount of elevation of shoulders and arms (common if you work on high table tops or high kitchen work stations, or if you sleep with your arms above the head, or if you are a musician who plays string instruments) you are a prime candidate for double crush syndrome. Some people are born with predisposing anatomical abnormalities, e.g., Roos' bands in the neck and increased carrying angle of elbows.

Many affected people are symptom free at rest but display symptoms with particular movements or exercise. This is because certain movements increase localised pressure on the tethered nerves. The mechanism of injury is thought