Stopping the Repetition

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June 2004

By Arlette C. Loeser, MA, OTR, CEA

When serving as the opening speaker for a Repetitive Stress Injury (RSI) Awareness Day Symposium at New York University in February, I found that addressing recovery issues and prevention of reinjury of the upper extremity with an RSI was paramount for both patients and practitioners. Recovery from an RSI of the upper extremity due to computer overuse is a long, tedious process. In my experience, I have seen many express their frustration with the recovery phase "never being over." In fact, the path to recovery and performing daily life tasks without pain can take months and even several years.

For the purpose of this article, the ergonomic principles for RSI are broken down into two categories: conceptual and practical ergonomics. The expertise involved with medical and therapeutic treatment interventions will not be addressed, yet the information here is crucial to anyone working with injured individuals and to the individuals themselves. Conceptual ergonomics for the RSI patient address ideas and thought processes derived by observing and experiencing successful healing and remaining injury free. Practical ergonomics for the RSI patient address the logistics of workstation design, equipment selection, and work behaviors.

CONCEPTUAL ERGONOMICS
One of the most effective means of understanding what will facilitate a successful recovery process is also the most challenging. It is the ability to step back and view the recovery process, from onset to the present. This is necessary for monitoring improvement and identifying recovery milestones. Mentally logging and analyzing can lead the patient and practitioner to understanding the source of exacerbations of the condition or of improvement, and it enables them to look beyond the present. This can afford the opportunity for continued identification of new strategies for healing by combining used and successful interventions and developing new ones with data gathered through one's experience. This can keep a patient moving forward both mentally and physically.

Many patients struggle in finding a treatment team with a successful track record of patient recovery. With hospital-based programs addressing RSI specifically, it has become easier to find the right treatment team members, but that is mostly in larger cities. Often a patient's condition can worsen during the search for effective treatment, and experience has demonstrated that early intervention is key. The reward, once the patient is working with an experienced practitioner, is immediate pain reduction and a better understanding of the healing process.

Protective strategies are implemented at every stage of recovery, with even the smallest increments of improvement. As symptoms decrease, implementing what works and sustaining the strategy can move the patient forward. Some recovery milestones may be obvious but not consciously noted as a tool for learning. When the patient observes a change in their ability to perform activities with less or no pain, or a later onset of discomfort, they can learn what effected this change and leverage it to continue healing. Other milestones to be noted are a patient's improved morale and optimism, and their ability to self-monitor and integrate new healing strategies.

Once the patient takes on the role as part of the team, they more actively participate in their own healing process and are more assertive as to what they need to do in order to heal, in their personal or work life. Recognizing these concepts can be empowering to the injured individual. That empowerment is most useful in one's ability to perform the most basic daily life tasks, such as brushing hair or being able to use a computer keyboard for less than 20 minutes without discomfort.

PRACTICAL ERGONOMICS
Practical ergonomics for the individual with RSI address the logistics and practical applications in the workstation. This category can be divided into the following categories: seating and posture, workstation design and setup, computer input device selection, and work behaviors.

When considering interventions for injured individuals, consideration must be given to changes that have occurred in anatomical integrity and activity tolerance. Differentiations in workstation design, body positioning, and chair selection all impact work behavior strategies. For example, when examining the "neutral reach zone," the reach distance may be different based on decreased range of motion, upper extremity use, and impact on the rest of the upper trunk.

Principles that can help to guide a patient to a newly modified workstation include: acknowledgement of a new midrange for establishing neutral posture, encouraging freedom of movement to be integrated into a work setup, and assessing each individual with full possibilities for customization to their particular anatomical changes. The individual with RSI generally must go beyond the search for the "comfortable" chair, since sitting position, materials, and chair contour are critical to the upper body's position and sensitivities. Some patterns identified for seating solutions include a concentration on high-quality padding (seat and back) in order to distribute the pressure, in particular the body prominences such as the scapulae given the common findings of diminished muscle development.

Integrating lumbar support has two areas of concern-support size and position. These are best achieved by a chair that offers an adjustable lumbar curve, and by examining the degree of lumbar support and how to ensure its proper positioning. This usually means the acquisition of a new office chair, selected specifically for the individual. A third key area is the armrest positioning and material options. While armrests are welcomed by users for rest periods, they very often prove to be a hindrance to free arm movement needed to prevent awkward postures, limited muscle lengthening or shortening, and joint stiffness.

In the selection of a keyboard and related devices-such as a mouse-identifying the positioning and range of motion of comfort of the individual's arms can narrow the options of devices that can be used. The shape, size, weight, and amount of force required to activate a keyboard or mouse can affect the individual's endurance and pain response. Specifically, the angles created at various joints, such as the wrist, will effectively promote a neutral position or irritate a vulnerable muscle group. A variety of devices available on the market offer the possibility of carefully returning to computer use. Many individuals find that alternating and/or integrating their input devices during the course of their computer activities allows for adequate muscle recovery time and increased arm use for functional activities.

The level of intensity and frequency of taking breaks can change the longevity of a work period. With two kinds of breaks incorporated into the individual's use of the injured body part, one can pace activity output, thereby implementing some control over the quickness of onset and degree of irritation. The 5- to 10-second spontaneous "microbreak" can give the muscle a brief recovery period to keep it from tightening up. Microbreaks are not effective unless they are performed in conjunction with forced task breaks, which are taken in less frequency but for greater lengths of time, ie, 5 minutes, every 20 minutes. When prescribing breaks for an individual with an injury, there is no recipe for how often and long they should be, since this determination is directly linked to the sensitivity of the muscles, endurance, and how quickly their pain cycle begins. The break schedule should be determined by analyzing the above variables, and then adjusted based on its effectiveness in decreasing discomfort. Multitasking activities can also be incorporated into the break schedule in order to vary the use of different muscles. Other work behaviors to examine closely are postures and movements assumed when performing tasks, as most people are not aware of upper body movement when working. Ideally, observing the individual at work is most effective so their natural behaviors can be analyzed and adjusted over time. One final overriding consideration for workstations is offering the greatest amount of body movement in the work area. This allows the arms, shoulders, and upper back to move freely and reposition easily.

CONCLUSION

This overview skims the surface of intervention for individuals with RSI. When implemented properly in conjunction with appropriate medical and therapeutic management, the individual can progress toward recovery and prevent reinjury.

Arlette C. Loeser, MA, OTR, CEA, is president of The Ultimate Workspace, New York, a consulting firm providing comprehensive ergonomic solutions in the workplace.

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June 2004