Repetitive strain


By Darren  Tilley 
Note this article has been updated with more info, photos and references in POSITIVE HEALTH MAGAZINE. Issue 163, October 2009. The online version is at the following address:-

I winced in agony as jagged, white hot bolts of lightning shot up from my wrists and deep into my muscles, riding up my forearms like demons from hell.


The darkest cloud of gloom and despair settled over me. I tried to light-heartedly chat with the patient whose head I’d just lifted in order to assess her neck. Soon my attempts at banter degenerated into silent, despairing thoughts of what I would do for the rest of my life. It was becoming more and more clear that my career as a therapist was over…


It had all started around three or four months ago, but maybe long before that, if I had taken notice of the signs.


Although classically trained and qualified as a remedial manipulative therapist, I’d come to realise through practise and my own experience that understanding and working with muscles was a very effective way of relieving painful conditions for the long term.


I had gradually moved away from the traumatising ‘clunk click’ of high velocity thrust joint manipulations into a deep understanding of muscle anatomy and physiology. I was using this understanding to achieve sometimes extraordinary results, and building a thriving practise that only a year before had allowed me to move to a wonderful four bedroom detached house with my two young children. I’d converted the large garage into a waiting room, and a very reasonably sized treatment room... Life was good.


I was now faced with the prospect of losing it all. I knew that I could possibly develop a career in teaching. I had spent three years as a college lecturer teaching anatomy and physiology and sports/ remedial massage. But I felt my prospect as a therapist looked bleak.


Looking back, the signs of what is known as RSI (repetitive strain injury) should have been obvious. Remedial work to muscles can sometimes require deep sustained pressure at all sorts of odd angles, with the fingertips, thumbs and palms.


 Every now and then, whilst performing the techniques, the ache in my wrists would seem to exceed the effort I’d actually put in. However, when I stopped work for the day the pain would miraculously disappear. And so it went on.  Gradually though, my attention became more and more focused on my wrist discomfort. Some of the movements I was using were causing me fairly deep pain; I put it down to overwork. I made sure I used good technique, with straight wrists, as all the books and authorities say, used the electric couch to achieve perfect posture during my work, all the usual stuff. But things continued to worsen.


A good portion of my working day was now a struggle. Almost everything I did was starting to create a lancing lightning pain that radiated from my wrists up into my forearms. But as soon as I took the pressure off, the pain would go, and for a lot of techniques I could use my fists, knuckles or elbows.

Looking back this had at least one positive; I developed an excellent sensitivity in my elbow and knuckles, or in reality, an increased ability to interpret the feedback from these tools.


However, there were some techniques that I just couldn’t adapt, the seemingly simple act of lifting someone’s head and applying mild traction caused me excruciating pain.  My focus was becoming much more centred on my own pain rather than my patients.  By this time I knew I had a serious problem.


Almost every day I was attempting some form of massage on my forearms in an attempt to relieve the pain, a tall order when the hand you’re using to massage the other arm with is sending messages of agony to your brain!  Despite success in my practice using muscle balancing techniques, I couldn’t fix myself!


I was starting to use painkillers and pain relief gels regularly, just to get through the day.   A small voice in the back of my head, probably borne of the volumes of text I had read on muscle physiology, was telling me this wasn’t the end, but for the life of me I couldn’t figure out what to do.  In desperation I tried herbalism, homeopathy, acupuncture, ultra sound; I finally went to other sports massage therapists when I could no longer massage myself.  Nothing seemed to help.  Each day was misery.  I was breaking my cardinal rule, of telling patients about my own aches and pains; which to my mind  was a bit like taking your car to a mechanic who couldn’t get his own car working!   I found myself trying to explain to patients why I couldn’t do some of the things I wanted to; I was losing hope.


I decided there was only one thing for it, rest.  Surely if this was an RSI type problem then rest would help.  I determined that a week off should do the trick.  I took my two gorgeous children down to Devon, camping.  I decided that I’d massage myself and stretch each day, and by not stressing my hands, everything would be ok.  I did as much and felt great.  I hadn’t had one bit of pain.  I had massaged my arm with my knuckles and all felt well.  This was it I was sure.  I knew the physiology of RSI.  I had read volumes of literature written by so many experts.  All would be well…


But what happened with my first patient, after my week off, in the first seconds of my first treatment that Monday morning, is described at the beginning of the article you’re reading… 


I felt my world had ended.


This was it, my career was over, and I was another ‘victim’ of RSI.


I continued to work in agony by day and, as men are wont to do, wallowed in self pity by night. But at some point I determined to understand and beat this.  Something told me I could, and in that moment, I vowed I would…


It’s amazing how the universe turns in your favour once you decide upon a course of action and really commit to it. In quick succession I had two breakthroughs.  The first was isolytic release, a part of the ‘Muscle Energy Technique’ approach to normalising muscles


Isolytic release is designed to break down adhesions between muscle fibres and between connective tissue and muscle fibres. Working with a fairly heavy  dumbbell, I began the process. This had a fairly dramatic effect on my discomfort, at least allowing me to work with my knuckles effectively, if not always with my fingers.


Despite having read numerous books on ‘saving your hands’ by various therapists, I still had some fundamental but little understood truths to learn about neuromuscular physiology.


A friend who is a teacher of tai chi and qi gong had come across some exercises that he felt were quite extraordinary, namely the ‘Five Tibetan Rites.  Upon his recommendation, I had bought two books on the subject and started practising these yoga type moves everyday.


At first I could barely get my wrists or neck into some of the positions required because of the pain.  I had to adapt by altering the positions slightly or doing a very poor approximation of them, taking my weight on my knuckles rather than my palms and so on. As my ability to do the exercises improved, there was a corresponding improvement in the wrist pain while working.

I began to see a glimmer of hope on the horizon.


I had also ordered a book from the United States called ‘It’s not carpal tunnel syndrome’ by Suparna Damay and Jack Bellis, and in reading this had confirmation of what I had begun to suspect about why the isolylic work and the Tibetan Rites were having such a beneficial effect.


I had always suspected that RSI was a somewhat fictional diagnosis.  If there are literally millions of typists in the world, why do only a very small percentage of them succumb to RSI.  If repetitive strain injury really existed, then surely all people working in that field would be subject to it.  But in reality only a few develop symptoms.  How could that be?


The answer is quite simply that in some people the nerves supplying the wrist muscles are slightly compromised, meaning that these muscles are getting slightly altered messages from the central nervous system.  This results in normal stress creating abnormal strain on the affected muscles.


If these muscles are subjected to continued repetitive stress they begin to fail, becoming prone to spasm and swelling resulting in the classic symptoms of RSI, which is not really repetitive strain at all, but more the result of a condition known as Thoracic Outlet Syndrome (TOS).


TOS is well documented in osteopathy as the cause of many neurological type symptoms in the shoulders arms and hands, but not so widely recognised as the cause of RSI.


This is because in suspected RSI, where the predominant symptoms are wrist pain, often diagnosed as carpal tunnel syndrome or something similar, TOS is mild and asymptomatic often with no pain at all in the neck, shoulders or chest. (As with my own case)  Nonetheless, TOS is there. It leads to a dysfunction of the muscles supplied by the nerves that are compromised and therefore a higher likelihood of those muscles becoming irritated and painful.  This leads to a degree of swelling in the tissues which may become viscous, then glue like, and can then create adhesions in various points throughout the arm musculature and it’s connective tissue, particularly in the wrist flexor tendons.


It was these adhesions that the isolytic work had begun to address, and the TOS that the Tibetan Rites had begun to resolve.  With this knowledge I began to use my understanding of muscle balancing in the correct areas.  The turnaround was dramatic, with only a few minor setbacks, which only served to increase my learning curve. 


Now, five years later my practice is still thriving and I suffer no pain in my wrists, despite more sustained ‘repetitive stress’ than ever! More importantly I recovered while working!


This experience was the impetus for considering how best I could help others, who suffer from the same kind of pain. Whether they are typists or manual body-workers or in fact anyone suffering from pain apparently due to repetitive work.


I now regularly run seminars aimed at qualified body workers who wish to understand more functional muscle anatomy and physiology, and the techniques required for successful and effective treatment of all musculoskeletal pain.