Strength Training and Repetitive Strain Injuries

(Excerpted from the new book, "(Amazon) It's Not Carpal Tunnel Syndrome: RSI Theory & Therapy for Computer Professionals"

Muscle Strength

If you notice difficulty opening jars, carrying grocery bags, opening doors, and so on, RSI has probably affected your muscle strength. In advanced stages of RSI, even coordination problems become apparent. This can include awkwardness fastening buttons, overshooting while shaking hands or picking up objects, and difficulty writing. When muscles become weak they cause joints to become unstable and create imbalances with opposing muscles. This in turn causes other muscle groups to compensate. In extreme cases, muscles gradually forget their function and movements become uncoordinated and inefficient.

Contrast with Endurance Muscle tissue consists of red and white fibers. The red fibers respond slowly to stimulus, but can sustain contraction for a considerable time. The white fibers respond quickly to stimulus, but are unable to sustain the contraction, and fatigue easily. This is the difference between the familiar dark and white meat of poultry. You might not be surprised then, to learn that the two types of fibers have to be trained in different ways. That’s why we address strength and endurance separately. In general, strength is easier to achieve than endurance.

How the Muscles are Damaged In an individual with RSI, loss of muscle strength is caused by any of the following: Early on in the progression of RSI, it can be difficult to decide which one of these factors is causing the decreased strength, so all three are usually considered and treated. Later in the progression of RSI, it is often clear if the nerve itself is the problem.

Strength Is Needed For Static Positions You won’t always notice overt signs of weakness. Many RSI sufferers feel just as strong with most mechanical activities, but they have lost a lot of strength in the routine suspension of the arms and upper torso. This makes it hard to work without resting your arms and slouching forward. Muscles perform work even though they’re not in motion. This is called a static or "isometric" work, and posture is certainly a prime example. RSI patients often complain of inability to sit for any length of time, and a need to support the head because "the shoulders cannot hold it anymore." So posture presents both strength and endurance problems. Strengthening the musculature is a large part of the solution, but maintenance of a balanced posture also has to be trained.

When to Start Strengthening The goal of therapy in the initial stages is to help the body heal, since the body cannot heal by itself anymore. Usually, when the body has healed to a point where you are mostly pain-free at rest (although the pain may return on activity), you are ready to start strengthening exercises. Increasing your strength should not be done at the cost of increased pain. There’s one simple rule: if the strength exercises cause persistent pain, it’s still too early. However, note that some soreness is inevitable, just like the soreness that you feel when exercising after a lengthy period of inactivity. By the time strength exercises are initiated as part of your rehabilitation program, you’ll probably be capable of distinguishing between the "good" soreness of exercise and the "bad," I-hurt-myself type of pain.

Restore Full Range of Motion While performing a movement, the resistance placed against a muscle, and consequently the strength the muscle must afford, varies based on the angle of movement. Muscles are most efficient and able to exert the most force in the relatively small range of motion used in daily activities. However, to encourage joint mobility and good circulation, it’s important to exercise the full range of motion.

Startup Reps As a rule, strength exercises should be increased slowly. There is no rule that ten repetitions of an exercise have to be performed on the first day. If you fatigue at fewer repetitions, stop. Do not set a goal for yourself and try to complete it regardless of your symptoms. There is no need to hurry since muscles strengthen quickly, and within a short time, you’ll get to ten repetitions.

Emphasize the Scapula First Begin with the scapular exercises (described shortly), in which you lie on your back and lift your arms in three positions: at your side, overhead, and out to the side. Many patients find that the arms feel better rather quickly, whereas the neck and back symptoms linger on, perhaps because they are the first to develop problems. The scapular strength exercises often result in a reduction of symptoms at the neck, provided they are begun at an appropriate time in the therapy. After you’ve become comfortable with the scapular exercises, you can proceed to the other strengthening exercises.

Use of Weights With the arm and scapula exercises, start without any weights. Using weights too early can aggravate your symptoms. After you’re comfortable performing about 20 repetitions with each exercise, it’s time to include minimal weights such as soup cans. When you can do 20 reps with this weight, you can progress to one-, two-, and three-pound weights. After three pounds, it’s up to you. You may want to increase the weight up to five pounds or stay at three.

Exercise Daily Exercises should be performed daily to start off with. Then, as a progression is made to weighted exercises, the frequency may be decreased to perhaps three times per week.

Practice Good Form More important than the weight is to use good form when doing strengthening exercises, so that compensatory movements do not occur. While performing strength exercises without a therapist, watch for "trick" or "substitution" movements where you change the angle of the movement or use a different set of muscles to complete the range of motion for an exercise. Concentrate on the muscles you are supposed to be working. A common example of substitution is when you use the neck muscles to cheat on shoulder movements or other upper arm exercises.

Manual Resisted Exercises (MREs) No exercise can substitute for the value of manually resisted exercises in which a therapist applies resistance to the movement. A highly experienced therapist can work against many of the problems we’ve described: imbalance in muscle groups, proper range of motion, and coordination. MREs can be the best way to retrain the correct muscle action, while preventing complementary movements. For a patient who has a serious condition and is not perfectly disciplined in conducting his or her own exercise regimen, MREs are the only realistic solution. Only a therapist can modify the resistance based on the strength of the muscle in the different ranges of motion, and adjust the exercises as the patient progresses.

Maintenance As long as the root cause of your problems—repetitive work—cannot be eliminated, your individual battle against RSI will be an ongoing process. Strength exercises should be continued on a regular basis, three to four times per week even after you feel you’ve recovered.

How Important Is Strength Training?

In our travels across the RSI terrain we learned of a patient who had serious carpal tunnel-like symptoms and made a remarkable recovery under the care of a personal fitness trainer. Anxious to learn his secrets and find out if his techniques were consistent with our ideas, we contacted him and interviewed him at length. The results were quite reassuring. Here’s what we found out.

His name is Fred and he’s a Certified Exercise Instructor, running his own company. Although not a physical therapist, he’s been involved in various aspects of physical therapy for ten years. He worked at New York’s Hospital for Joint Diseases and founded and ran a sports medicine practice at Methodist Hospital along with a leading orthopedic surgeon.

The patient in question is a hair stylist, who learned about Fred because she happened to be cutting the hair of one of Fred’s employees. She complained of severe aching and burning in her hands and wrists, increasing over the course of a year and a half, until it became incapacitating. If the symptoms were limited to pain alone, she would grudgingly have continued to work through the pain… but when she couldn’t hold the scissors in her hand anymore, she was ready to sell her business. She had been cutting hair for 20 years and, being self-employed was an acknowledged workaholic. She described her pain level as "10" on a scale of 1-10. An orthopedic surgeon and a neurologist told her about using ice and other palliative techniques but suggested that ultimately, surgery—carpal tunnel surgery—was her only recourse. Other than the fact that she knew she had had a nerve conduction velocity test, not much diagnostic information was available. (Although this patient is a hair stylist, not a computer worker, what we learn will be just as valuable.)

We asked Fred, "was she physically fit?" thinking of one of the more debatable predisposing factors for RSI—even some very healthy looking people have problems. This is where we dive headlong into Fred’s theory and strategy. Irrespective of her overall health, in Fred’s view she was not physically fit for the work she was doing, and that’s all that matters. All activities are muscle specific, and the muscles that held her arms up and worked the tools of her trade were fatiguing and inflaming. Says Fred: "Health is substantially a matter of metabolism, and 80% of your working metabolism is from muscle tissue. Disorders that arise from weakness must be countered by strength." To endure strenuous activity, progressive resistance exercises are critical. Moreover, some of the more popular trends of physical fitness, such as obsessive running, are doing a disservice if they cause you to reduce muscle mass, or even fail to maintain it. Most people really believe that recreational activities keep their muscles strong and healthy. But this is simply not true if muscle mass is slowly decreasing. And the aging process alone will cause you to steadily lose muscle mass, if you don’t fight back.

Fred’s therapy therefore consists almost entirely of strengthening exercises, and that’s how he made her well. Strengthening enhances joint flexibility and vascular efficiency. He strengthened her whole body, her legs, back, and specifically arms. He used a Nautilus biceps curl machine and grip machine, both specially retrofitted for better results. Fred especially emphasizes slow-speed strength training. In this technique, a weight is used that is light enough that the patient can sustain the action for at least 40-60 seconds, but heavy enough to cause momentary muscle fatigue in at most 90 seconds. And note that multiple sets are not performed. Another technique he uses is timed static contraction. With this method the patient holds a position until complete fatigue occurs. This is what you might know of as "isometric" exercising. Both techniques strive to completely fatigue the muscle in the shortest possible time, with as little articulation of inflamed joints as possible, for the utmost safety.

And how did his client progress? After only three session of ½ hour each she started to get significant relief—so much so that she canceled her appointment with her surgeon. She was treated for 17 once-a-week sessions and now has almost no pain. As we’ve seen with our patients, she had a setback at about the 8th week, with an increase in pain believed to be from some strenuous lifting she had done. She’s back to working full hours and has given up that wrist brace someone told her to wear. She also has increased the chores she does around the house, which she had greatly curtailed. She continues a regimen of strength training on her own. We said his therapy was almost all strength training, so what else does he recommend? He tells his clients to drink one gallon (!) of water a day.

Before evaluating this case history, an important word of caution: this is the story of a therapy for which you will most likely NOT be reimbursed by medical insurance. Fred, like many alternative therapists, is not a physical therapist, let alone a licensed physician. It is not out of the question, however, to have a physician authorize alternative treatment so it can be reimbursed, and insurance situations are changing hourly. The only certainty is probably this: you will only find out what you can get if you fight for it.

So what wisdom can we derive from this therapist’s wonderful results? First, we certainly believe it substantiates—and elevates—the value of strength therapy. And, it highlights, from another source, an experience where surgery was one step away, yet apparently inappropriate. The only question is what it implies about other aspects of our therapy, some that you’ve already read about, and others that you will read about soon: massage, stretching, and ergonomics. In other words, if strengthening alone helped this patient, is that the whole answer? We believe not. Strength training may have been exactly what this individual needed and was ready for; others are simply not ready. Our experience seems to show that a small number of RSI patients have a seriously diminished capacity for muscle recovery. Some advanced cases don’t seem to recover the same strength levels as "normal." They would be traumatized if they start weight training without a chance to reduce their inflammation and aches and pains. Too many patients are put into a "work hardening" program administered by individuals without the expert touch someone experienced in RSI. Fred himself is quick to point out that many practitioners don’t have much specific training in how to remodel tissue safely. The other point to remember is that his patient was not a computer pro, but a hair stylist, which almost certainly has more variety of hand motions and postures. Differences aside, we feel Fred’s success speaks volumes. Here’s how we put it in perspective: in contrast to massage and stretching which will help heal damage that has already been done, strengthening (and ergonomic changes) will help cure you—keep you less susceptible to damaging yourself again.

Muscle Endurance

The capacity of a muscle to sustain prolonged activity is called its endurance. RSI sufferers will usually have both weakness and fatigue symptoms, so it’s important for a therapist to explain the difference between the two to the patient, since endurance is slow to increase. It’s not unusual for the process of improving endurance to continue for six to twelve months or more after the patient has been discharged from rehabilitation. This slow return to your prior level of endurance is one of many frustrating aspects in the RSI healing process. Another consideration is that endurance is very activity specific. Many of us know this phenomenon from skiing or other sports that we only occasionally partake in—we’re extremely sore after just a few hours of skiing for the first time each year. This means that just because you might be able to vacuum two rooms without any increase in symptoms, it does not mean that you can necessarily wash a car. Each new activity has to be trained, and as you recover from RSI, you are essentially rebuilding your muscle mass. What were once very familiar activities are once again "new" to your body. As you exercise to restore your endurance, you must be aware of what your body is telling you and avoid overdoing it. This is an aspect of RSI recovery that therapists particularly need to instill in every patient.

Repetitions Versus Weight Muscle strength and endurance go together, but strength is quicker to progress. Only increase weight resistance after establishing some progress with endurance at each level. A good guideline is that once you can do three sets of ten repetitions for a given exercise, the weight may be increased. Each time a progression in weight has been made, drop the repetitions down to what you can accomplish, and gradually work up to three sets of ten again. For example, work with a one-pound weight until you can do three sets of ten. When this is comfortable, increase the weight to two pounds, but drop back the repetitions to one set of ten. In time, work the repetitions back to three sets, and increase the weights again. Some exercises are more difficult than others—don’t force yourself to advance just as rapidly with every exercise.

 

"I had good success doing the "lat raise" exercise. It’s a weight machine in which you lift weights with your elbows. It really improves the shoulder muscles. I could only do about 30 pounds when I started, but was surprised how rapidly I got up to 70… a likely indication that I had lost a lot of capacity over the years. I worked up to this by doing three sets of ten. When I could do three sets of 13, I moved up ten pounds and dropped back to 10 reps."

-- Patient E.

Record Your Initial Capacity Make a serious effort to get baseline information when you start exercising. Especially with exercises for the hands and arms, where you can compare one hand to the other, you can get very revealing diagnostic information. When you first try the various exercises, do them once or twice until exhaustion, and write down your results. Remember, you only have one chance to get baseline information… once you start exercising, your circumstances change.

 

"I started doing wrist curls with a 3-pound weight and could do about 60 before my left hand was completely exhausted. Then I tried my right and was surprised to find after 200 I could keep going, almost as if I had no limit. No wonder my left hand has nerve problems."

-- Patient E.

Time Your Working Fatigue Cycle When you are typing and using the mouse, time how long it takes you to fatigue or have pain. Then, the next time you’re typing, try to take a break before you reach that limit. Over a period of time, you can try to gradually increase that time slowly, a few minutes at a time. Your tendency will be to forget about your limits and increase the continuous keyboarding time until the discomfort returns. The key is not to flirt with disaster, but rather, to be very in tune with your body’s changing capacity and stay within your limits. The idea is not to stop after fatigue, but before it happens.

Aerobic Exercise Aerobic exercises, also called conditioning exercises are fast, high-intensity activities that get your heart pumping and your lungs working. They’re extremely important because they increase blood supply to inflamed body parts, which is vital in the healing process. Another healing benefit of aerobic exercise is that it reconditions your overall sense of vitality and endurance. Because of your RSI, you’ve probably become somewhat de-conditioned, not just in the parts where you feel symptoms. The body as a whole needs to regain strength and endurance. Aerobic exercises should be started early in the rehabilitation program. It can consist of a variety of activities including a stationary bicycle, walking on a treadmill, jogging, or "aerobics" programs. And you should definitely continue some aerobic exercise as part of your routine after your rehabilitation has been completed. But don’t get so obsessed with aerobics that you end up decreasing your muscle mass. As we learned earlier, you need that muscle mass to provide strength and boost your metabolism.

Returning to Work and Play If you’ve persevered through an arduous rehabilitation or post-surgical period, you’ll probably have to relearn many skills and build up your endurance again. Some people may also be returning to a workstation that has had ergonomic improvements while they were away from work, recovering. So it will be normal to experience fatigue and discomfort. Listen to your body… when you’re tired and achy, rest and stretch. Gradually things will get better.

If you have stopped activities such as gardening, handiwork, or hobbies because of your symptoms, when you are ready and you restart, your symptoms may recur. Don’t get discouraged. Stop when your symptoms occur, but gradually, over days, weeks or months, increase your activity in small increments. If you’ve been out of work, your rehabilitation may include what is referred to as "work simulation" before you return to work. Here you actually simulate your work conditions and practice your work activities. Be warned, however, that the first time you sit at a computer workstation after a period of time, it is going to be rough. You may not be able to make it through the first five minutes, but as days go by, you will see improvement. Just make certain that you work only at a workstation that is completely adjusted to your individual specification.