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 to relate to loss of blood supply to nerves, leading to decreased transport of neurotrophic (or nerve growth promoting) substances in the entire nerve. Healthy nerves must be able to glide freely in their soft-tissue beds. Scarring around a nerve at a localised site will tether the nerve, and restrict its mobility. Movement of the limb with associated muscle pull and joint movement will produce a further traction injury to the nerve just above and below the point of tethering. Next week: diagnosis and management

(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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Managing double crush syndrome
Author: Dr Deepak Sharan
Bangalore, The Times of India, August 7th, 2004

A nerve is like an electrical wire transmitting signals from one end to another. If there is a minor amount of damage (injury) in the wire, there may not be a perceptible change in the signal transmission (symptoms). But if a small amount of additional damage happens at another area further down the wire, the additive effects of both injuries may then affect the signal. This, in turn, causes noticeable transmission problems (symptoms) at the original site. And since the second area of damage was too small to create symptoms on its own, it may go undetected unless the entire wire is meticulously tested.

A comparison of neurological testing at rest and then subsequent to provocation of the patient's symptoms may be the only way a diagnosis of double crush syndrome can be made. Routine nerve conduction tests will be either normal or misleading and the typical signs of nerve damage like muscle atrophy or abnormal sensations will be absent.

The treatment of double crush syndrome is essentially non-operative. Known systemic causes, e.g., diabetes, alcoholism, vitamin deficiency, hypothyroidism, etc. may require specific medical treatment. Otherwise, medicines, in general have little role. The mainstay of treatment is work modification and specialised physical therapy, comprising of soft tissue mobilisation, neural glides, and myofascial release. Where appropriate, affected individuals are advised to minimise repetitive activities, overhead activities, or prolonged use of vibratory tools. Education of the patient as to the positions of the extremity that will exacerbate pressure around the entrapment sites is critical. An example is advising patients to sleep in a military position with their arms by their sides (with the elbows slightly extended) to avoid prolonged pressure at entrapment points during sleep. Surgery could be dangerous in situations where the possibility of nerve compression at more than one level cannot be ruled out with certainty. Otherwise, recurrence of symptoms on return to the job is inevitable.

(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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It's not Carpal Tunnel Syndrome
Author: Dr Deepak Sharan
Bangalore, The Times of India, August 14h, 2004

The headline is the title of the best selling book on repetitive strain injuries (RSI) by Suparna Damany and Jack Bellis. When faced with pain, numbness, tingling, stiffness, burning or swelling in the hands and fingers, the general tendency nowadays is to jump to a diagnosis of carpal tunnel syndrome (CTS), with little consideration given to other possible causes. In fact many computer users and lay people (who rely on the internet for information on RSI) consider CTS synonymous with RSI.

CTS refers to the compression of the median nerve at the wrist, due to inflammation or the lack of blood flow to the nerve. The carpal tunnel is an opening within the wrist formed by the carpal bones and a thick band of ligament. The median nerve, blood vessels and tendons pass from the forearm into the hand through this tunnel. If the tendons become inflamed and swollen in this small space, they may press against the median nerve. Over time, this pressure may result in nerve damage and a decrease in the sensory and motor function of the thumb, the first three fingers and the palm of the hand.

However, recent research in the US and India is now showing that what was earlier thought to be CTS is often turning out to be one of the following:

Double Crush syndrome or compression of median nerve in the wrist along with multiple levels of compression in the forearm up to the neck.

Thoracic outlet syndrome or neurovascular compression in the opening under your collarbone.

Myofascial trigger points (tiny contraction knots) in as many as 38 muscles in the neck, chest, upper back, shoulder, upper arm, forearm and hand.

The implication of this knowledge is that even though all the symptoms are in the wrist and hands, there will be no relief unless specific treatment is carried out in the neck!

(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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Learning the Alexander Technique
Author: Dr Deepak Sharan
Bangalore, The Times of India, August 21st, 2004

Over the past few weeks, I have been learning the Alexander Technique (AT) from a British teacher. Although unheard of in India, AT is well established in USA, Europe and Australia.

AT is an educational method that shows people how they are misusing their bodies due to work habits that create excessive amounts of static loading and how to reduce the unnecessary muscular force they are applying to their bodies. AT was developed by Fredrick Matthias Alexander (1869-1955), an Australian farmer-turned-actor with no academic or medical background.

Alexander was a sickly child who barely survived a stormy childhood to become a Shakespearean stage actor. Unfortunately, he developed a voice disorder and was unable to recite his lines. His doctors advised voice rest for a few months. When he returned to the stage, the problem persisted. Multiple tests turned out normal and he was told there was nothing wrong with him and was advised more rest cure. After unsuccessfully visiting a variety of medical and not so medical practitioners, he decided he had to find out for himself what was wrong because penury beckoned. Alexander figured out that the problem had something to do with what he did on stage, as he did not have any trouble with his voice when he was not acting. His co-actors told him that he made a gasping sound as he breathed in between lines.

Alexander then set up mirrors at strategic locations and observed himself when he spoke normally and when he recited. He discovered that when he got ready to recite he drew in air with a loud gasp and tensed his neck muscles pulling his head back and down. He also made his entire body shorter and tenser, restricting his breathing and freedom of movement. By means of prolonged, tedious experiments Alexander found a way of preventing this pattern from initiating during recitation. He subsequently found new and better ways of using the various parts of his body involved in reciting. The final result was that Alexander's voice trouble vanished and thus was AT born.

(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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Benefiting from an AT Lesson
Author: Dr Deepak Sharan
Bangalore, The Times of India, August 28th, 2004

What is common between Paul Newman (actor), Roald Dahl (author), Sting (singer), John Cleese (comedian), George Bernard Shaw (playwright) and a host of musicians and opera singers worldwide? All of them practice(d) Alexander Technique (AT) in their daily lives. Dr. William Barlow, a Consultant Rheumatologist in UK, was a prominent AT teacher, and AT is still practiced in several NHS pain clinics in UK. Yet, unlike many complementary modalities AT makes no sale pitch at being a cure-all.

AT is not a therapy, though it has therapeutic effects, but an educational process. It is not something where you just lie down passively and let a practitioner treat you. It teaches you not facts, but how to learn about yourself, for yourself, what habits of body use you have and how you can prevent the harmful misuse.

During the lesson, the teacher guides a student to improve coordination in activities like getting up from a chair and sitting down, and lying down without tensing the muscles, skillfully using his hands to provide the tactile feedback. AT prevents or inhibits misuse due to subconscious, habitual directions and then builds up the primary control with consciously chosen directions, leading to a more effective use of the body. After each lesson, I could experience enhanced body flexibility, and a subtle perception of increase in the length of spine and limbs. Like me, many people take AT lessons, not because of health problems, but because they find it a valuable tool for improving their wellbeing and self-knowledge. Some also take it for painful conditions like RSI.

Most people need about 30 lessons of 45 minutes each before they can successfully begin applying AT on their own. I think the key to success with AT lies in finding a highly skilled and experienced teacher, and by taking individual (rather than group) lessons. At present there are no AT teachers in India, but I plan to have an eminent teacher from the UK visit Bangalore twice a year to give lessons.

(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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Know your psoas well
Author: Dr Deepak Sharan
Bangalore, The Times of India, September 4th, 2004

The psoas is: (a) An endangered reptile. (b) The latest rival to Windows. (c) The core muscle of your body that is the key to your structural stability. If you didn't answer c, read on.

The psoas muscle (pronounced so-as) is located deep within your pelvis, close to the gravitational forces, and attaches to the 12th thoracic vertebrae (approximately at the level of your midriff) and to each of the 5 lumbar vertebrae. The muscle passes through the pelvis and attaches to the inner thighbone in the groin called the lesser trochanter of the femur.

The psoas muscle is a guy wire for the spine. It is the only muscle to connect the spine to the lower limbs, and is critical for balance, alignment, joint rotation and range of motion. Sitting for long durations with a contracted psoas interferes with blood circulation and diaphragmatic breathing, and affects functioning of vital abdominal organs and the immune system. A short psoas tilts the pelvic bone forwards, minimising the space between the pelvis and the thigh, compresses the hip socket, preventing the thigh from moving separately from the trunk. Movement of the thighbone, instead of happening in the ball and socket of the hip joint, begins to occur as twists in the knees and torques in the lumbar spine.

The commonest reasons for a shortened psoas in patients include poor chair design (hollow or bucket type seats, or seats sloping backwards), short people in huge chairs, high work surfaces, sitting with the knees higher than the hips, dangling the feet in air while sitting, habitual muscle tension, falls, surgery in the pelvic region, overenthusiastic exercising or weightlifting. Infants who stand and walk prematurely (before proper bone formation) or those who are put in walkers and playpens too early, learn to rely on their psoas (rather than their bones) for structural support, and may face back problems later on.

(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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Releasing your psoas
Author: Dr Deepak Sharan
Bangalore, The Times of India, September 11th, 2004

Entire books have been written on the psoas muscle (e.g., The Psoas Book by Liz Koch). Experts who treat muscle related pain call it the "hidden prankster", because abnormalities in the psoas (e.g., Myofascial trigger points) are among the commonest causes of low back pain, stiffness and sometimes shooting pain and numbness down the legs, and even knee and pelvic pain. Some alternative medicine modalities in the west like core working are entirely based on stretching the psoas for various disorders, which I think is carrying things too far. In yoga, the psoas plays an important role in many asanas.

The diagnosis of psoas dysfunction is made by physical examination, and blood tests, x-rays and MRI Scans are normal (or show something totally unrelated and insignificant, e.g., small disc bulge or spondylosis). Unfortunately, conventional physiotherapy (traction, radiation/heat over the back), medicines, ointments/balms, spinal braces or surgery do nothing whatsoever to relieve this problem.

Skilled myotherapists can release the psoas using special neuromuscular techniques, muscle energy techniques and positional release techniques, often with dramatic and instantaneous symptomatic relief. This will need to followed-up by specific stretches and activity modification(s).

Here are some practical tips to keep your psoas healthy:

Sit on a chair with a firm, flat seat. If your chair has a hollow or bucket type of seat modify the chair using a firm wedge shaped foam cushion.

Sit with your hips higher than your knees. The chair may be raised upwards to achieve this.

Sit with your weight in front of ischial tuberosites (sitting bones deep within your buttocks). Most people sit putting their entire weight behind the ischial tuberosities leading to tilting of pelvis and rounding of the lower back.

Place your feet firmly on the floor. Use a footrest if necessary.

Computer users must ensure that their keyboard and mouse are placed at the level of their laps and no higher. Do not reach out for the keyboard or the mouse.

Avoid tight-fitting shoes and high ankle boots.

Learn relaxation techniques to release habitual muscle tension
(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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Of triggers and trigger points
Author: Dr Deepak Sharan
Bangalore, The Times of India, September 18th, 2004

Voluntary muscle is the largest organ system in the human body. Among patients seeking treatment for musculoskeletal pain, myofascial pain syndrome (MPS) has been reported in 30% to 93% of all patients, in numerous medical studies. Despite its high prevalence, MPS remains undiagnosed and untreated in most cases.

MPS is characterised by the presence of myofascial trigger points (TrPs), which are tender, hypersensitive points in skeletal muscles contained within palpable taut bands. You can feel them as painful lumps of thickened tissue, like nodules or small peas. Pressure on a TrP produces local pain at the TrP site and often produces distant referred pain (or abnormal sensation) that is similar to a patient's usual symptom.

Three theories have been proposed to explain why TrPs develop. The first theory suggests that MPS results from TrPs, which in turn are caused by repetitive muscular overload (microtrauma) or direct muscle injury (macrotrauma). The local hypersensitivity and pain at the injury site leads to painful local muscle contraction and development of TrPs.

The second theory is based on pain neurophysiology, and proposes that the TrP is not a primary muscle lesion, but entirely a referred pain phenomenon. The primary nociceptive (pain producing) source is in the dorsal horn of the spinal cord or in the peripheral nerves.

The third theory assumes that TrPs originate from dysfunction at the muscles themselves. Local muscle spindle dysfunction and abnormal depolarisation of motor endplate, is thought to be the mechanism. The resultant muscle spasm may impair blood supply to the muscle leading to depletion of oxygen, calcium and other nutrients necessary to produce muscle relaxation. Continued spasm causes distortion and damage of involved tissues, leading to release of inflammatory chemicals, which further increases perception of pain.

Unfortunately, international research on finding the true cause of TrPs has taken a backseat perhaps because of lack of funding and interest from pharmaceutical companies for obvious reasons.

(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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The endless web
(39th Article under the "IT's your health" series)
Author: Dr Deepak Sharan
Bangalore, The Times of India, September 25th, 2004

The headline is the name of a famous book on fascia (by Schultz and Feitis). Fascia is a flexible network of soft tissues that surrounds, cushions, and supports virtually every structure in our body including muscle, bones and organs. It is also called the body's packing material or the connective tissue. Fascia is the white, glistening, transparent covering you sometimes see on a chicken breast right under the skin.

Fascia actually has three layers, but it is all continuous and three-dimensional. The fascia of your head is connected to the fascia in the toes. This explains why many people with Repetitive Strain Injury (RSI) have generalised pain and why poor neck posture causes pain in the legs!

Whenever we think of movement, we usually think of a muscle contracting leading to physical movement across joints. Fascia is the structure that makes the movement happen in a smooth and coordinated manner. Myofascia is fascia that is present around and within muscle tissue. Each time the muscle contracts or relaxes; movement is transmitted to periosteum (the covering layer of bone) through the fascia.

Sometimes due to mechanical trauma (e.g., habitual tension, or holding the muscle contracted for long durations) or biochemical trauma, the myofascial covering becomes thickened and the muscle is unable to lengthen and to move freely. Similar adhesions can form across nerves and blood vessels leading to impaired neurovascular function. Fortunately, this toughening of the myofascial sheath is reversible and techniques like Myofascial Release, Rolfing and Hellerwork can restore natural elasticity to the diseased myofascia.

There is no specific field of medicine dealing with fascia, and yet it is critical to virtually every clinical specialty. The tragedy is that as medical students we spend just a few hours studying the fascia in a course lasting 5 ½ years. Though absolutely vital for life, one doesn't even see the fascia in dissected cadavers because it shrivels up after death. This perhaps explains why so many people forever remain in pain, because myofascial dysfunction can mimic many conditions and affect many body systems. What we perhaps need is an emphasis on the study of the living anatomy rather than the anatomy of the dead.

(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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Symptoms of MPS
Author: Dr Deepak Sharan
Bangalore, The Times of India, October 2nd, 2004

Myofascial Pain Syndrome (MPS) is characterised by the presence of myofascial trigger points (TrPs), which are tender, hypersensitive points in skeletal muscles contained within palpable taut bands. You can feel them as painful lumps of thickened tissue, like nodules or small peas. Pressure on an active TrP produces local pain at the TrP site and often produces distant referred pain (or abnormal sensation) that is similar to a patient's usual symptom.

This pain pattern is usually similar from patient to patient and is typical of each muscle. In fact, a specialist in the treatment of myofascial pain can usually predict the location of active TrP's from the patient's symptoms, without even touching the patient. Such a TrP hurts whenever you use the involved muscle, e.g., driving, eating, and combing the hair. An active TrP causes symptoms even when the muscle is at rest. A latent TrP doesn't hurt at all, unless you press it and you might not even know it's there.

TrPs typically cause muscle weakness, incoordination and dysfunction before they cause pain. Symptoms include illegible handwriting, poor grip strength, buckling knees, and weak ankles. TrPs can compress blood vessels, lymph vessels and nerves, because these structures pass through the fascia ("the endless web"), leading to numbness, tingling, burning, electric shock like sensations, coldness, skin discolouration and swelling. Other associated symptoms may include stiffness, muscle tightness, muscle cramps, localised sweating, chest pain, dizziness, tinnitus, pelvic pain, diarrhea, nausea, goose bumps, runny nose/eyes, eye strain, jaw pain and headaches.

The vast majority of Repetitive Strain Injuries (RSI) in IT professionals is accounted for by MPS. However MPS can affect anybody, including housewives, children and the elderly.

Next week: factors that aggravate MPS

(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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Factors that aggravate MPS
Author: Dr Deepak Sharan
Bangalore, The Times of India, October 9th, 2004

According to Travell & Simon's seminal text on Myofascial Pain and Dysfunction, and similar medical textbooks, the following factors are known to typically aggravate Myofascial Trigger Points (MTrP's):

Strenuous use of the involved muscle. Judging the precise movement that produces pain is one way of diagnosing Myofascial Pain Syndrome (MPS). This may indicate the muscle harbouring the TrP's.

Forcible, passive stretch of the muscle, e.g., traction, conventional stretching

Sustained or repeated contraction of the involved muscle, e.g., while lifting weights or doing isometric or strengthening exercises

Local pressure on the TrP's, e.g., a vigorous massage

Keeping the affected muscle immobile in a shortened position for a long time, e.g., after sitting in a fixed position, driving, sleeping, and by using neck collars, back belts/corsets and braces

Sitting under the cold draft of the air conditioner or an open window

Cold, damp weather

Viral infections, sore throat, respiratory infections, etc.

Chronic allergies, including food allergies

Excessive, uncompensated emotional stress or psychological tension

Depression

Sleep disturbances

Hypothyroidism

Nutritional deficiencies, especially folic acid and pyridoxine deficiency

Smoking, caffeine, and alcohol

Anaemia

Recurrent bouts of hypoglycemia

Hyperuricaemia (high uric acid levels)

Some situations when TrP's suddenly get activated include accidents, falls, direct blow to the muscle, sudden lifting of heavy weight, twisting movements, intramuscular injections, appendicitis, heart attack, being bed bound for a prolonged period, operations and infections. An interesting observation is that muscles supplied by a compressed nerve following a slipped disc can develop TrP's (post-disc syndrome). Unless these TrP's are identified and treated even surgical removal of the disc (discectomy) may be unsuccessful in relieving pain.

Gradual development of TrP's is usually due to incorrect posture, abnormal bone structure (short leg, tilted pelvis, short upper arms, etc.), poor body mechanics and ergonomic issues related to work station set up, job design, etc.

(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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Factors that relieve MPS
Author: Dr Deepak Sharan
Bangalore, The Times of India, October 16th, 2004

To avoid trampling on sensitive toes, I will confine discussion of the modalities that have been shown to be consistently successful in relieving Myofascial Trigger Points (MTrP's) by quoting directly from Travell & Simons' text on Myofascial Pain and Dysfunction, and similar authoritative medical textbooks. Methods other than those mentioned below may be promising or may have had anecdotal success but cannot be considered recommended therapy based on current medical knowledge.

Myofascial pain syndrome (MPS) is responsible for directly causing up to 85% of all pain conditions in all age groups and in all professions. MPS also accounts for the vast majority of Repetitive Strain injuries seen in Computer professionals.

Myofascial TrP pain is decreased by the following modalities:

By a very short period of rest.

By slow, steady passive stretching of the involved muscles, especially under a warm shower.

By application of moist heat on the TrP (and NOT at the site of pain). However, patients will need to be shown exactly where the TrP's are located.

By short periods of light activity with movement (not by isometric contraction or strengthening exercises).

Specific manual therapy or myotherapy: Trigger point pressure release, Myofascial release (MFR), Muscle Energy Techniques (MET) and Positional Release Techniques (PRT).

Clinician administered Spray and stretch.

Clinician administered TrP injections.

Trigger point pressure release (or TrP therapy) is done as a painless but uncomfortable barrier-release technique to release the contraction knot in the muscle. The amount of pain felt by the patient should not exceed 7 on a scale of 10 at the time of treatment (0 = no pain; 10 = maximum pain). Digital pressure or tools can be used to achieve TrP release; however, a very high order of manual skill and experience is required to achieve this. This technique relies entirely on accurate identification of MTrP's by means of palpation. With proper instruction, this can be achieved, in certain cases by patients themselves, using rubber balls and self massage devices. Next week: MFR, Spray and Stretch, and TrP injections

(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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Releasing TrP's effectively
Author: Dr Deepak Sharan
Bangalore, The Times of India, October 30th, 2004

Having evaluated where a restricted area exists, Myofascial release (MFR) techniques can be added to improve flexibility and restore musculoskeletal balance. MFR is a hands-on soft tissue technique that facilitates a stretch into the restricted fascia. During MFR a sustained gentle pressure is exerted in the line with fibre direction of the tissue being treated, which engages the elastic component of the elastico-collagenous complex, stretching this until it commences, and then eventually ceases, to release.

Muscle Energy Techniques (MET) are soft tissue manipulative methods in which the patient, on request, actively uses his muscles from a controlled position, in a specific direction, with mild effort against a precise counterforce.

Positional Release Technique (PRT) involves positioning an area or the whole body in such a way as to invoke a physiological response, which helps to resolve musculoskeletal dysfunction. The beneficial results seem to be due to a combination of neurological and circulatory changes, which occur when a distressed area is placed in its most comfortable, its most easy, most pain free position. (As described by Chaitow, 1996)

Clinician-administered spray and stretch involves sweeping a stream of vapocoolant spray over the muscle in a series of parallel sweeps that start at one end of the muscle and continue over the muscle belly to include the referred pain pattern. This is followed by a myofascial release maneuver or sequential isometric contraction and relaxation (Lewit technique). Spray and stretch produces an immediate increase in pain threshold accompanied by improved range of motion. Travell and Simons state, "Spray and stretch is the single most effective non-invasive method to inactivate acute trigger points (TrP's)." This needs to be maintained by a home-exercise programme of appropriate stretches and self-care of the injured area.

TrP injections are used as a method of directly inactivating TrP's particularly those refractory to myotherapy, a situation common in chronic, neglected MPS. The TrP is penetrated with a fine needle, eliminating the TrP as a painful focus. It is not necessary to inject drugs during TrP injection, and steroids in particular are strongly not recommended. Botulinum toxin has been proposed as a method for resistant MPS, but further investigation is needed to define whether it has a place in the management of Myofascial Pain Syndrome (MPS). A TrP injection is not the same as acupuncture.

(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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Paradoxical breathing and RSI
Author: Dr Deepak Sharan
Bangalore, The Times of India, November 6th, 2004

Breathing is the single most important activity we do to stay alive. Difficulty in breathing, e.g., during airway obstruction, is a truly frightening experience.

Essentially, there are three ways of breathing:

Apical, which takes place at the top part of the chest. Your chest and shoulders rise and fall when you are breathing this way.

Intercostal, which takes place from the rib cage.

Diaphragmatic, or abdominal breathing, which takes place below the rib cage. Your tummy moves in and out as you breathe.

At rest, healthy breathing should be a combination of intercostal and diaphragmatic breathing patterns. The latter is considered the healthiest. You should feel the belt tighten up each time you breathe in.

Paradoxical breathing occurs when your tummy flattens as you breathe in and expands as you breathe out. This is exactly the reverse of how healthy breathing takes place. The presence of painful trigger points in and around the muscles involved in breathing promotes shallow or apical breathing.

People who suffer from Repetitive Strain injuries (RSI) typically develop abnormal breathing patterns, because of adopting sedentary, fixed sitting postures. Abnormal breathing patterns are among the commonest perpetuating factors delaying recovery from RSI and Myofascial Pain Syndrome (MPS). This is especially so in anxious or depressed patients and those with habitual muscle tension. Yet, it the factor that is perhaps the simplest and the cheapest to treat, provided you make the required effort. Several techniques like Yoga, Alexander Technique, Feldenkrais, Pilates, Somatics, etc. give a lot of attention to improvement in breathing patterns.

The benefit of learning correct breathing techniques lies in the improvement in nutrition and oxygen supply to muscles, tissues, nerves, glands and organs. The gentle expansion of the ribcage due to movement of intercostals or rib muscles leads to improved flexibility of the upper body. The spine is also kept supple and lengthened. Slow, deep breathing helps to counter the stress responses in the body by calming the nerves. It is also critical to breathe deeply while exercising as this facilitates relaxation and allows the mind to relax into the rhythm of movements.

(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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RSI and Headaches
Author: Dr Deepak Sharan
Bangalore, The Times of India, November 13th, 2004

Headaches are frequently reported by people suffering from Repetitive Strain Injuries (RSI): an overuse soft-tissue disorder common in but not exclusive to computer users. Headaches have several known triggers: allergies, chemical withdrawal, hormonal imbalances, physical trauma and emotional tension. However, not many know that referred pain from myofascial trigger points (TrPs) is among the commonest causes of headaches.

The common muscles that harbour headache producing TrP's include Sternocleidomastoid (found in the side of the neck), Trapezius and Levator Scapulae (upper back), Suboccipital muscles, Splenius, Semispinalis Capitis, Multifidi and Rotatores (back of neck), Masseter, Pterygoid, Buccinator (jaw), Orbicularis Oculi (eye), Frontalis (forehead), Occipitalis (back of the head), and Temporalis (between eyes and ears).

Common causes of TrP's in the neck muscles include:

Whiplash injury (motor accidents in which you are typically hit from behind)

Slouching

Sitting in head forward position (vulture neck attitude)

Holding the telephone receiver between the head and the shoulder

Looking at a laptop screen that is too low

Poorly fitting glasses or improperly corrected vision

Improper chair armrests

Sleeping on the stomach with the head turned to one side

Using a thick pillow

Working with the head turned to one side, e.g., using 2 monitors or keeping the monitor at an angle

Carrying heavy backpacks or laptops

Heavy breasted women

Overhead work, e.g., painting the roof, hanging curtains

Writing on a blackboard

TrP's in the jaw muscles can arise due to:

Dental infections

Dental procedures

Mouth breathing

Excessive gum chewing

Habitual jaw clenching

TrP's can develop in posterior cervical muscles due to:

Tight hats and headbands

Heavy glasses or heavy overcoats

Cervical collars

Most factors known to trigger headaches actually do so by activating latent TrPs. This can commonly happen due to colds, viral infections, overexertion, hangover, analgesic (pain killer) rebound, and reactive hypoglycemia (following excessive sugar consumption).

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

Symptoms of Myofascial Headaches
Author: Dr Deepak Sharan
Bangalore, The Times of India, November 20th, 2004

The typical feature of headache due to a Repetitive Strain Injury (RSI): an overuse soft-tissue disorder common in but not exclusive to computer users, is that the pain is variable and changes with the position of head or muscular activity. The headache may be so intense that it affects your thinking and overall functioning. Associated symptoms may include giddiness, eyestrain, droopy eyes, ringing in the ears or deafness, deep-seated ear pain or burning, difficulty in swallowing, pain in sinuses, throat, teeth or jaws, and a runny nose.

A TrP in the semispinalis capitis muscle (found behind the neck) creates a headache like half a headband, with the highest intensity in the temple and over the eye. These TrPs can cause nerve entrapment leading to numbness, tingling and burning in the scalp at the back of the head. Patients with these TrP's have reported that they are unable to place their heads on the pillow due to incapacitating pain. Pain due to TrP's in Multifidi and Rotatores muscles feel like it's in the spine itself and is often misdiagnosed as resulting from disc compression or cervical spondylosis, especially if x-rays or MRI scans show degenerative changes (which are, however, ubiquitous and have little, if any, correlation with symptoms). Posterior cervical TrPs below the skull can also produce pain in the hands and feet on both sides, or to the body below the shoulder on the same side as the TrP. The basic reason why TrP headaches are often missed is that TrP's are rarely found in the head itself: the pain is invariably referred to the head from affected muscles in the jaw, neck and upper back.

Obviously, TrP's are not the only cause of headaches, but should certainly be considered in the differential diagnosis because of their high prevalence. Like TrP's elsewhere, these TrP's respond poorly to medicines but gets relieved by myotherapy (TrP therapy, myofascial release, and spray and stretch).

(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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RSI and Traveling by Air
Author: Dr Deepak Sharan
Bangalore, The Times of India, November 27th, 2004

Many professionals suffering from Repetitive Strain Injuries (RSI): an overuse soft-tissue disorder common in but not exclusive to computer users, are obliged to undertake air travel. Carrying heavy luggage and sitting in cramped seats in airports and airplanes for prolonged periods can aggravate an existing RSI. As airlines compete to pack in more and more passengers, RSI patients are especially hard hit because of less legroom and less space to move around.

Here are some tips when preparing to travel:

Request an aisle or bulkhead seat in advance.

Avoid carrying heavy pieces of luggage (including laptops) in your hands.

Pack sensibly, use wheeled luggage (strolley) or a backpack, and always use baggage carts/trolleys in the terminal. Push the trolley instead of pulling it.

The cabin baggage should not weigh more than 5% of your body weight.

While keeping cabin baggage into the overhead compartment stand directly in front of the compartment and avoid twisting or turning your neck or back.

Place the pillow provided by the airline or rolled-up blanket behind your lower back (just above the belt) to maintain the natural S-shaped curve of the spine while sitting. An alternative is to use the pillows to either side of your lower back, or to make an inverted T with them.

Carry an inflatable pillow and place it across the gap between your neck and the headrest.

If the seat is worn out, use folded blankets to support your buttocks.

An obvious solution is to avoid economy class (if eligible and affordable)!

Ask your doctor for medications that can help in controlling pain and muscle spasm during the flight.

(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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Air travel without pain
Author: Dr Deepak Sharan
Bangalore, The Times of India, December 4th, 2004

Continuing where I left off last week on prevention of pain for Repetitive Strain Injury (RSI) patients during air travel, some further tips include:

When placing luggage under the front seat, do not make twisting movements of your legs, feet or arms. Sit down first, and using your hands and feet, gently guide your bag under the seat. Keep adequate space under the seat in front of you for your feet.

While reading, place the book or newspaper on a book-holder or clipboard in front of you so that the head does not bend down.

Tilt the back rest 10 degrees backwards and sit with your back supported.

While sleeping avoid twisting or turning your head.

Try leaning forward during ascent, to prevent the tailbone from being compressed.

Prop your foot on a bag if your feet dangle up in air.

While seated, vary your position frequently to improve circulation and avoid leg cramps. Rub the leg and calf muscles using the other foot. Move your legs and knees frequently.

Turn the air vent away from you, because the cold draft can increase tension in your neck and shoulder muscles. Keep yourself warm.

Stand up and in the aisle as often as possible (every 20-30 minutes on a long-haul flight).

Drink plenty of water rather than alcohol, coffee of tea to prevent dehydration.

Carry watertight plastic freezer bags with you on the plane. If your back hurts during the trip, you can ask the cabin crew for ice. Put the ice in the plastic bag and apply it on your back for 10 minutes.

If you wish to receive a list of suggested exercises that you can do during the flight, email me with "Airplane Exercises" in the subject line.

(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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Is RSI more common in women?
Author: Dr Deepak Sharan
Bangalore, The Times of India, December 11th, 2004

Repetitive Strain Injury (RSI) is a group of overuse disorders affecting the soft tissues, typically of the neck, back and the upper limbs. Accurate data on the incidence and prevalence of RSI's are sparse. In India, our ongoing study has reported that 75% of over 5000 computer users reported musculoskeletal symptoms. There are no population registries of RSI anywhere in the world, and not all people affected seek medical care. Hence, most available data perhaps underestimates the true magnitude of these disorders.

Being female is widely reported as a risk factor for many RSI's because several studies in the west have shown that women are twice as likely as men to develop neck and shoulder symptoms (though less likely to develop low back pain). Our data and that of others in the west suggests that women are also more likely to quit or change their jobs on developing RSI. Some authors believe that the high prevalence of RSI among women could be explained by an increased tendency to report pain and inability to suffer silently! Apart from computer users and receptionists, a very high prevalence of RSI has been reported among women performing hand-intensive tasks like garment manufacturing, assembly line work, laundry, nursing, cleaning, and cooking.

Some factors that make women more susceptible to RSI's include:

Occupational demands: more immobility at workstations and more repetitive motion patterns

Poorly designed workstations and chairs

More monotonous job content

Lower job decision latitude

Amount and type of household work

Levels of psychosocial stress outside the work environment

Type of recreational activities, e.g., knitting, watching TV, reading, telephone usage and SMS

Physiological factors

The good news for Indian IT/ITES women professionals is that, unlike their western counterparts, they are outnumbered 4:1 by men as far as RSI is concerned. This may or may not be significant overall because there are disproportionately more males in the sector.

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Factors causing RSI in women
Author: Dr Deepak Sharan
Bangalore, The Times of India, December 18th, 2004

Several physiological factors may predispose women to the development of Repetitive Strain Injury (RSI).

Muscle strength and muscle fiber type distribution

Women's body strength is, on average, about 2/3rds that of men's, and this difference is especially marked in the upper extremities. There is some evidence (though not conclusive) that less strength and flexibility of the neck and shoulder muscles is an important risk factor for the development of RSI. Whether strong back muscles protect against low back pain remains debatable because though stronger muscles are capable of generating higher internal forces, they do not imply greater strength in other soft tissues, such as nerves and spinal discs. The near-continuous firing of low-threshold motor units in muscles during static work has been proposed as a mechanism for the selective injury of individual muscle fibres, even when the muscle as a whole is not fatigued. Women, on average, have a higher relative volume of slow-twitch (aerobic) to fast-twitch (anaerobic) muscle fibres than men. It has been hypothesized that women (with more slow-twitch fibres) may be less likely to alternate among muscle motor units during low-force contractions.

Tendons, ligaments and connective tissues

Tendons in women tend to have different responses to repetitive motion exposures than those in men. Tendons of the hand in women have been measured to be stiffer than in men on application of tension. Tissue creep (time-dependent elongation) is less pronounced in female than in male tendons. Tendon and ligament cells in women seem to be strongly influenced by sex hormones and pregnancy-related factors. Studies of sex hormone receptors in connective tissue indicate that fluctuating hormonal influences during the menstrual cycle or during pregnancy may contribute to differences in regulation of ligaments and tendons and subsequent development of RSI. Women also seem to be more prone to neurogenic inflammatory responses leading to tendinitis (inflammation of tendons), tenosynovitis (inflammation of tendon sheaths) and peritendinitis (inflammation around tendons).

Hormonal factors

Low back pain has been anecdotally associated with menstruation, oral contraceptive use, induced abortion, number of live births, menopausal symptoms, and lower age at menopause.

Next week: The Effect of Pregnancy on RSI

(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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The Effect of Pregnancy on RSI
Author: Dr Deepak Sharan
Bangalore, The Times of India, December 25th, 2004

It is well recognised that pregnancy increases the risk for development of Repetitive Strain Injuries (RSI) and aggravates existing RSI's.

Several factors make women more susceptible to RSI during pregnancy:

Increase in body weight.

Changes in body weight distribution.

Weakness of abdominal muscles.

Altered connective tissue function, e.g., increased joint laxity, perhaps due to release of relaxin and other hormones.

Differences in the fit between body and workplace dimensions, e.g., pregnant women sit further away from work surfaces, hips are positioned further backwards, with increased compensatory trunk flexion, and arm flexion.

Lifting capacity is altered towards the end of pregnancy as the center of gravity moves forward and as increased body size prevents objects from being lifted close to the body. Pregnant women are at increased risk for low back injury during heavy lifting, standing and frequent climbing of stairs.

Carpal tunnel syndrome, a compressive neuropathy of the Median nerve in the wrist, is frequently associated with pregnancy, perhaps due to excessive fluid retention in the carpal tunnel. Fortunately, the nerve compression is usually reversible and improves after delivery.

After the birth of the child, a flare up of RSI symptoms can commonly happen due to several factors, including the physical strain of carrying and feeding the baby, disturbed sleep, distorted sleeping postures, and psychosocial factors (stress).

Regular stretching and strengthening exercises, yoga, and relaxation positions are necessary to prevent worsening of symptoms. It is essential to provide pregnant women (in particular) with adjustable work surface height or adjustable trays for the keyboard and mouse to reduce postural strain. Also, there may be a case for a slightly more prolonged maternity leave for IT/ITES women professionals already afflicted with RSI, to allow for prolonged soft tissue healing.

(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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RSI and Heel Pain
Author: Dr Deepak Sharan
Bangalore, The Times of India, January 8, 2005

Pain in the heel is a common accompaniment to Repetitive Strain Injuries (RSI): a group of overuse soft tissue disorders common in (but not exclusive to) computer professionals. Myofascial trigger points (MTrP's) are hyperirritable spots within a taut band of skeletal muscle in a muscle fascia that are ubiquitous in RSI's. The spot is painful on compression and can give rise to characteristic referred pain, tenderness and autonomic phenomenon.

TrP's in the calf muscles (gastrocnemius and soleus) typically cause referred pain, numbness or burning sensation in the heels, mimicking plantar fasciitis (strain of plantar fascia), colloquially called a heel spur. What is even more confusing is that TrP formation has an element of "chicken and egg." For example, heel pain can radically alter a walking pattern, which may lead to an abnormal muscle firing pattern and development of TrP's in the calf muscles.

Many cases of heel pain presumed to be due to plantar fasciitis that do not respond to conventional methods of treatment like physiotherapy, soft rubber soles (e.g., MCR Chappals), local steroid injections and anti-inflammatory medication eventually turn out to be due to MTrP's. However, it is necessary to exclude systemic arthritis (e.g., Rheumatoid arthritis, Ankylosing Spondylitis, Reiter's syndrome) and sarcoidosis as a cause of heel pain. Early, aggressive myotherapy gives the best possible chance of a good outcome in this condition. The treatment modalities found to be consistently effective include TrP therapy employing ischaemic compression or deep cross fibre friction, myofascial release, spray and stretch (employing a vapocoolant spray), and TrP injection. Occasionally, adjunctive modalities like cryotherapy, iontophoresis or phonophoresis may be required (in the calf and not in the heel!). Taping techniques can provide short-term relief and appropriate stretching of the gastro-soleus complex is an important factor in successful rehabilitation.

(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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Calcaneal Spur and Plantar Fasciitis
Author: Dr Deepak Sharan
Bangalore, The Times of India, January 15, 2005

Plantar fasciitis is a type of Repetitive Strain Injury (RSI) leading to an inflammation of the plantar fascia (a connective tissue that runs from the heel to the base of the toes). If the fascia is placed under abnormal repetitive loads there is microtearing of the tissue resulting in inflammation, pain and scarring.

Calcaneal or heel spurs are soft calcium deposits that are the result of tension and inflammation in the attachment of plantar fascia to the heel bone. Contrary to popular belief, heel spurs usually do not cause pain. The reason why the term heel spur is equated with heel pain is that the spur can be seen on an x-ray, the idea of a bony spur poking into soft tissue provides a believable and understandable cause of pain even if it's an erroneous description, and because it is easier on the tongue than plantar fasciitis. In fact, the heel spurs are not spike-shaped at all, but flat and shelf-like. They look like spikes because x-rays are taken from the side looking down along the edge of the shelf. Medical studies indicate that 8-21% of the normal population has heel spurs. Plantar fasciitis is caused by a change in load demands on the plantar fascia that can be due to increased activities, poor footwear (no arch support or cushion, or the toe portion does not bend back easily), poor foot biomechanics (how the foot functions on weight bearing), or an increase in body weight. It is more common in people who spend too much time on their feet, e.g., teachers, postmen, surgeons, bus conductors, and in certain sportspersons, e.g., step aerobics, volleyball, basketball and long distance runners. Sedentary life styles and desk jobs can lead to a lack of flexibility in the calf muscles, which places more strain on the fascia because the front of the foot is forced into the ground which strains the fascia.

Arthritis, stress fractures in the heel bone, loss of natural tissue for cushioning under the heel (fat pad atrophy), and tarsal tunnel syndrome (a type of nerve entrapment) can also cause similar pain.

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

What's causing your heel pain?
Author: Dr Deepak Sharan
Bangalore, The Times of India, January 22, 2005

How do you know whether your heel pain is due to plantar fasciitis or due to other causes, e.g., myofascial (referred) pain? Here are some broad clues:

The classic symptom of plantar fasciitis is excruciating heel pain with the first few steps in the morning.

Walking on the front of the foot may decrease pain due to other causes, whereas in plantar fasciitis the pain increases (due to increased tension in the plantar fascia). However, pressing the toes down while walking while taking full weight on the entire sole may decrease pain in plantar fasciitis (because of transfer of tension from the fascia to tendons and muscles in the calf). Similarly, pointing the foot inward toward the other foot while walking, and walking on the outside edges of the feet can decrease pain due to plantar fasciitis. Please note that these are just tests and we do not recommend that you start walking this way!

Typical plantar fasciitis patients are female, overweight, above the age of 30, have just started step aerobics after years at a desk job, or have a job that requires more than 6 hours a day of standing or walking.

Thinner heel pads, calcaneal spurs (even though they do not usually cause pain), and overpronated feet (inside ankle bone rolls downward too much when walking) are commoner in plantar fasciitis.

Pain of plantar fasciitis is quickly relieved on correct application of plantar tape. Pain due to lack of flexibility of calf muscles is usually relieved by application of a firm heel pad or calf stretch. Relief of pain after application of a soft heel pad may indicate plantar fasciitis, stress fracture or fat pad atrophy.

Frequently, plantar fasciitis and other causes of heel pain coexist. Next week: Self help measures for heel pain

(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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Self help measures for heel pain
Author: Dr Deepak Sharan
Bangalore, The Times of India, January 29, 2005

Different modalities help different people and seeking expert medical help early is a good start.

Rest: avoid activities that cause increased pain like excessive standing, squatting, uphill walking, taking longer strides or barefoot walking. Avoid running especially on hard surfaces until the pain has subsided. Swimming or walking under water is a good alternative activity. However, too much rest can lead to atrophy and more pain.

Ice: local application of ice after activity or injury reduces inflammation. The ice may be applied for 5 minutes about 5 times in a day till the inflammation persists. Standing on ice cubes placed within a towel or rolling a frozen soda bottle under the foot are different ways of applying ice.

Localized massage (if recommended) can reduce local inflammation after prolonged standing or activity.

Weight reduction: often easier said than done, especially if walking a few steps causes excruciating pain.

For relief of morning heel pain, stretch the plantar fascia, calf muscles, apply hot fomentation and gently massage the bottom of the foot before taking the first step. In some cases, use of a night splint that keeps the foot and calf muscles relaxed may reduce morning pain.

Frequent stretching of the calf muscles and plantar fascia after prolonged sitting and before walking is important. Toe and foot muscle strengthening, e.g., by picking up a towel using the toes may also be required.

Tape (or strapping) or Orthoses/Arch Supports can be helpful sometimes to protect the fascia and allow healing. It can also enable a patient with severe heel pain to walk again. However, you will need to learn the correct technique of tape application.

(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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Prevention of heel pain
Author: Dr Deepak Sharan
Bangalore, The Times of India, February 5, 2005

Persistent plantar fasciitis is an excruciatingly painful condition and efforts to prevent the condition from developing are ideal.

Obtain a go ahead from your physician before starting a new exercise regime. · Begin exercising slowly and increase the level gradually.

Learn the correct stretching techniques and remember to stretch adequately before and after exercise.

Avoid uneven walking terrains as much as possible and avoid going barefoot on hard surfaces.

Vary the incline slightly while walking or running on a treadmill.

Avoid jogging on a concrete surface or on a tarred road (if you can find one)!

Wear proper shoes while trekking or during pilgrimages. Stop frequently to rest and stretch.

If heel pain occurs, stop right away. Do not attempt to exercise through the pain.

Here are some recommendations for selecting shoes:

Have both feet measured every time you purchase shoes because your foot size usually increases, as you get older.

While a small heel may be beneficial, avoid a heel higher than 2 1/4 inches.

Sizes vary among shoe brands and styles. Select a shoe based on how it fits your foot not by the marked size.

Try on new shoes at the end of the day because your feet normally swell and become larger after standing or sitting during the day.

Shoes should be fitted snugly to your heel as well as your toes.

There should be 1/2-inch space from the end of your longest toe to the end of the shoe. You should also be able to freely wiggle all of your toes

The shoe should have an arch support, sufficient cushioning, and good flexibility in front of the shoe that allows the toes to bend back easily.

While tying the shoelaces, use all the eyelets, making sure that the area closest to the heel is tied tightly while less tension is used near the toes. When you have reached the next to last eyelet on each side, thread the lace through the top eyelet, making a small loop. Then, thread the opposite lace through each loop before tying it.

(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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Right posture keeps wrist pains away
(New series in the Wellness Supplement)
Author: Dr Deepak Sharan
Bangalore, The Times of India, August 26, 2006

When faced with pain, numbness, tingling, stiffness, burning or swelling in the hand, computer users who rely on the internet for health information automatically assume that they have carpal tunnel syndrome (CTS). The carpal tunnel is an opening within the wrist formed by the carpal bones and a thick band of ligament through which the nerve, blood vessels and tendons pass into the hand. CTS refers to the compression of the median nerve at the wrist, due to inflammation of surrounding tendons or the lack of blood flow to the nerve. Assembly workers, beauticians, data-entry operators, cooks, musicians, and racquet-sports enthusiasts are often affected. Risk factors include pregnancy, rheumatoid arthritis, hypothyroidism, renal failure, etc.

However, our study of over 12,000 computer professionals in India with Repetitive Strain Injuries (RSI) has revealed that CTS accounts for less than 0.5% of cases. What was earlier thought to be CTS is often either Double Crush syndrome (compression of median nerve in the wrist along with multiple levels of compression in the forearm up to the neck); Thoracic outlet syndrome (neurovascular compression in the neck) or Myofascial trigger points (tiny contraction knots) in the neck, chest, upper back, shoulder, upper arm, forearm and hand muscles. The implication of this knowledge is that even though all the symptoms are in the wrist and hands, there will be no relief unless specific treatment is carried out in the neck! Similar findings have been reported by researchers in USA and Europe.

No specific laboratory diagnostic tests exist and nerve conduction tests are helpful only in advanced nerve compression. The treatment of CTS is essentially non-operative, including work modification and specialised physical therapy, comprising of soft tissue mobilisation, neural mobilisation and glides, and myofascial release. Medicines have little role, though some studies have suggested a role for Vitamin B6. Painkillers may worsen symptoms by promoting further salt and water retention. Wrist splints may be useful for nighttime numbness and tingling, but should never be used while working. Surgery could be dangerous in situations where the possibility of nerve compression at more than one level cannot be ruled out with certainty, and should be kept as the last resort. Tips for CTS prevention include keeping the wrists straight and unsupported while typing, taking microbreaks of 5 seconds for every 5 minutes of typing, and getting trained in correct ergonomics and body mechanics.

Dr. Deepak Sharan, Consultant in Orthopaedics, Rehabilitation & Ergonomics

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Non-drug remedies for insomnia

(New series in the Wellness Supplement)
Author: Dr Deepak Sharan
Bangalore, The Times of India, August 26, 2006

What is insomnia?
According to the National Institutes of Health (USA), insomnia is defined as complaints of disturbed sleep in the presence of adequate opportunity and circumstances for sleep. The disturbance may consist of 1 or more of 3 features: (1) difficulty in initiating sleep, (2) difficulty in maintaining sleep, or (3) waking up too early.

How common is it?
10% to 30% of the general population and up to 50% of older adults have insomnia

What are the dangers of chronic insomnia?
* Impaired daytime functioning (e.g., ability to learn, remember, and concentrate), behavior, and quality of life
* Increased mortality, heart attacks, and accidents at workplace, at home or while driving
* Economic burden (over $100 billion/year in USA) including medical care, lost productivity and work absenteeism
* Increased risks of ADHD-like symptoms (especially in teens) and psychiatric disorders like depression

Why does it happen?
" Circadian rhythm disturbances (regulated by Melatonin), e.g., in call centre workers or jet lag
" Medical conditions, e.g., heart disease, hypertension, asthma or hyperthyroidism
" Chronic pain disorders, e.g., Fibromyalgia, RSI, Restless Legs Syndrome and arthritis
" Substance use or withdrawal, e.g., nicotine, alcohol, drugs
" Impaired cognitive function and negative emotions such as anxienty or stress
" Psychiatric disorders, e.g., depression
" Sleep apnea (difficulty breathing during sleep)

How long do I need to sleep?
The amount of sleep needed varies from person to person. Einstein needed 10 hours whereas Freud coped on just a few. The key is to wake up feeling refreshed, with sufficient energy for the day ahead. Adults generally need between 6 and 10 hours sleep, and children need between 9 and 10 hours.

What can I do to improve sleep?

1. Practice Sleep Hygiene (improving sleep habits)
" Exercise regularly, preferably in the late afternoon, but not within 2 to 4 hours of bedtime
" Eat a light, easily digestible snack or drink a cup of warm milk before bed but avoid large meals before bedtime
" Read at bedtime
" Keep your bedroom quiet and cool
" Do not watch the clock at night
" Avoid caffeine and nicotine for at least 6 hours before bedtime
" Drink alcohol only in moderation and avoid use for at least 4 hours before bedtime
" Improve the comfort of your bed if needed, e.g., pillow, mattress

2. Relax
" Diaphragmatic breathing
" Visual imagery relaxation
" Progressive muscle relaxation

3. Stimulus Control (re-associate the bed with sleep)
" Use your bed/bedroom for sleep only; do not watch TV, listen to the radio, eat, or read in bed
" Go to bed only when you are tired

4. Cognitive Restructuring (changing your thinking)
" Identifying your thoughts about sleep that tend to make sleeping more difficult and,
" Replacing these thoughts with more helpful thinking

5. Sleep Restriction and Scheduling
" Set a consistent wake up time that does not change, not even on weekends or holidays
" Stop daytime napping
" Get out of bed if you can't fall asleep within 20-30 minutes; return to bed only when you feel sleepy
" Restrict your time spent in bed to the amount of time that you actually sleep. For example, if you find that you generally get only about 6 hours of sleep a night, then don't go to bed until 6 hours before your wake up time (always give yourself at least 5 hours in bed each night). After a few nights of sleeping well on this schedule, gradually make your time to bed earlier until you are getting a full nights sleep.

What do Multidisciplinary Insomnia Clinics offer?
" Cognitive-behavioural therapy (retraining the patient to recognise and challenge anxiety producing beliefs about sleep and sleep loss)
" Relaxation training, e.g., progressive muscle relaxation
" Biofeedback
" Stress management
" Medical, psychological and nutritional evaluation and treatment
" Aerobic conditioning, fitness training, Yoga, meditation, etc.
" Pain management

When should I visit an expert?
" Feeling agitated, irritable or listless often
" Depression
" Reduced energy
" Reduced mental capacity
" Co-existing medical illnesses not getting better
" Chronic insomnia not responding to self-help measures

The author is a Consultant in Orthopaedics, Rehabilitation & Ergonomics
With inputs from RECOUP's team

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