I am very concerned that I could be developing RSI. What can I do, and what treatments either conventional or alternative have proven to be of use? EB, Swindon.....
Repetitive Strain Injury (RSI) has become an epidemic. The National Institute of Occupational Safety and Health in the US estimates that the problem has increased from 18 per cent to 56 per cent of all workplace maladies in less than 10 years. RSI now accounts for over half of all worker compensation claims.
This increase is pretty much down to the use of the computer. "Without stepped up keys to reach, paper to change or a carriage to push, computer typists get no breaks from activity that is drastically confined to the wrist and forearms," explains Dr Alan Hedge, director of ergonomic research at Cornell University, New York.
Despite its prevalence, there still remains a hard core of GPs who refuse to recognise RSI as anything more than yet another psychosomatic disorder, mainly because there is little supportive epidemiological or pathological evidence.
They can also be a bit sniffy about the language. RSI is not a medical definition; it is a layman's term for a range of symptoms affecting the muscles, nerves and tendons of the upper limbs which is collectively known by your doctor as carpal tunnel syndrome (CTS), bursitis or tendonitis, to name but three.
Your other problem is political. Doctors and, it's rumoured, UK government health agencies are reticent to recognise and diagnose a condition that can lead to expensive, and sometimes disputed, claims against employers.
Assuming you overcome all this and can find yourself a sympathetic doctor, there is a limited amount he can offer. Depending on the severity of the condition, he might prescribe an anti inflammatory, a diuretic or steroids.
Of the three, steroids seem to be the most effective, according to one double blind placebo study (Neurology, 1998; 51: 390-3).
In another study, the steroid prednisone offered rapid and effective relief for the first eight weeks only (Neurology, 1995; 45: 1923-5). This finding was also observed in another study involving 32 carpal-tunnel-syndrome patients, which found that the benefits of steroids were "transient" (J Neurol, 1993; 240: 187-90).
Your GP might also tell you to stop whatever's causing the RSI. Good advice, in fact, and by far the best thing to do is to stop it before it really starts. Once it takes hold, full recovery is uncertain and may go on for a very long time, irrespective of the treatment, conventional or alternative.
If you're getting early warning signals, such as numbness or tingling around the thumb or fingers, you must find a way to curb the activity. Even if you can't take time off work, learn to break up the day and walk away from the keyboards once an hour or so, or vary the workload so that you are not constantly keying in.
You also need to get advice about posture and the positioning of the keyboard and screen. The desk should be at an appropriate height without a sharp leading edge, and the keyboard should be spaced 8 to 10 cm away from the desk's leading edge.
Finally, try and use an ergonomically designed chair that makes your back do more of the work and prevents slouching. A good source is Back in Action (3 Quoiting Square, Oxford Road, Marlow, Bucks SL7 2NH; tel: 01628 477177).
There might also be a method of early detection, even before the tingling begins. Dr Bruce Lynn of University College Hospital in London and physiotherapist Jane Greening have used a machine called a vibrametre, produced by Somedic in Stockholm, Sweden, which detects a change in the nerve vibrations among typists who may go on to suffer RSI (Int Arch Occup Environ Health, 1998; 71: 29-34).
If your problem is more advanced, your doctor may well refer you to a specialist. As the average wait in Britain on the NHS to see a consultant is around seven months, and if you are wedded to the idea of staying with conventional medicine, you could book in to see an orthopaedic surgeon or a physiotherapist in the meantime.
The consultant more than likely is going to recommend surgery, particularly if your RSI, or CTS, is particularly chronic.
The UK support group RSI Association urges anyone to think twice before accepting surgery. "We are not aware of any surgery that has been completely successful. Ask the consultant for details of any patients whose surgery has been 100 per cent successful. He never can," says association chairperson Wendy Lawrence, an RSI sufferer for more than 10 years.
Her view is supported by the medical trials. In one study, incisions for carpal tunnel release, the standard procedure, on 47 patients resulted in pain and scar sensitivity (J Hand Surg, 1997; 22: 317-21). In another, involving 57 neuritis patients, surgery was no better than steroids (Int J Lepr Other Mycobact Dis, 1996; 64: 282-6).
Keyhole surgery is becoming a popular technique, but recovery with this form of surgery does not seem any better than with conventional surgery. In one study of 29 CTS patients, those who had the keyhole surgery suffered numbness in the ring finger (J Hand Surg, 1996; 21: 202-4).
Another new technique, involving the use of a glass tube with a groove which is inserted into the hand, is also of questionable value. In a trial using 10 hands from patients who had recently died, the cotton tip came off inside the incision of one hand, and the glass tube broke in another (J Hand Surg, 1995; 20: 465-9).
Other approaches your consultant might suggest include ultrasound or electrical therapy. A mixed bag of electro therapies has been developed in the last few years, possibly born out of the indifferent success of other conventional treatments.
The jury's out on ultrasound treatment. In one study, it was no more effective than placebo (Arch Phys Med Rehabil, 1998; 79: 1540-4), whereas another trial found that ultrasound did offer short term relief (BMJ, 1998; 316: 731-5). A better result was had with high voltage pulsed current (HVPC), which was passed through a wrist splint. Those who had the treatment were able to carry out repetitive tasks afterwards (AAOHN J, 1998; 46: 233-6).
Low level laser has been used with some success for long term management. The laser rapidly stopped the pain and tingling in the arms, hands and fingers of 35 CTS patients in one study, and the researchers believe it could be used together with physical supports, such as cervical collars (Int J Clin Pharmacol Ther, 1995; 33: 208-11).
According to research, CTS sufferers tend to be low in vitamin B6 (pyridoxine). A double blind trial using either placebo or vitamins found that the condition of those given the supplement improved to such an extent that surgery was not necessary (Proc Natl Acad Sci USA, 1982; 79: 7494-8). Wendy Lawrence at the RSI Association says that nutrition is an entirely new area of treatment, and that building the immune system has helped to ease the condition. Interestingly, she's noted that more than the expected number of RSI patients also suffer from either endometriosis or irritable bowel syndrome.
In view of the limited help that conventional medicine can offer, it's little wonder that the favoured route for many RSI sufferers is alternative medicine. Wendy Lawrence says that her members report greater benefits and pain relief using one of the alternatives, and of these chiropractic, osteopathy and Alexander technique seem to be the most favoured, although osteopathy seems to be of little use in treating chronic cases.
The types of alternative treatments which can help, depending on the extent of your RSI and your own inclination, fall into several groupings, as listed by RSI sufferer and author David Ruegg. The physical treatments are chiropractic, osteopathy and dietary supplements; postural therapies include the Alexander technique or Feldenkrais; relaxation techniques encompass massage, biofeedback and flotation tanks; exercise involves walking, swimming and jogging; stretching comprises yoga and stretching exercises; energy medicine is made up of acupuncture and healing; and cognitive behavioural therapy embraces pain clinics and counselling.
Scientific evidence for any of these therapies is in limited supply. Yoga exercises were tested on 42 CTS sufferers who went through a regimen of 11 postures to strengthen, stretch and balance each joint for eight weeks. The yoga group reported significant improvements in grip strength, pain intensity and sleep disturbance (JAMA, 1998; 280: 1601-3).
Chiropractic was tested against the use of ibuprofen (a non steroidal anti inflammatory drug) on 96 CTS patients and was found to be as good as but no better than the drug therapy (J Manipul Physiol Ther, 1998; 21: 317-26).
Osteopathy came out better in one trial when it was tried on 20 CTS patients with mild to moderate symptoms (J Am Osteopath Assoc, 1994; 94: 647-63).
Biofeedback was tested against relaxation training in a group of patients with a range of chronic, upper body traumas. All patients had immediate relief from pain, but the relaxation group expressed greater short term benefits. However, within six months there were no differences between the groups (Pain, 1995; 63: 199-206).
Useful UK contacts: RSI Association, tel: 0800 018 5012; British School of Osteopathy, tel: 0171 930 9254; Society of Teachers in Alexander Technique, tel: 0171 351 0828.