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A Rolfer's Approach To Working With Repetitive Stress Injuries
by Siana Goodwin, Certified Advanced Rolfer

The success of this work has been amply documented elsewhere; the purpose of this article is to present to fellow bodyworkers some of the observations and discoveries I made about RSI during the years that I worked for Starkey. When I began I had a relatively limited view of carpal tunnel syndrome. Like many of us, I assumed it to be entirely a problem of the wrist, since that is where the median nerve supplying the muscles of the hand is most vulnerable. As I worked and studied more, I found a variety of different factors in this and other RSI problems.

It's very common for people to refer to all repetitive stress injuries of the hand and arm as "carpal tunnel." I have even been informed that someone "carpal tunnel in the elbow." The specific condition of CTS is an impingement of the activity of the median nerve. Presence of CTS is identified by electromyography, which determines the conduction capacity of the nerve. Impingement of the nerve results in pain and tingling in the hand, but also muscle weakness in the intrinsic muscles of the hand, especially the flexor and opponens pollicis. In severe cases of CTS, these muscles atrophy.

However, there are conditions that can precede the onset of CTS, and these can also produce symptoms of pain and numbness. Usually these are caused by prolonged muscle tension, which results in restriction of blood flow. When blood flow is restricted, not only do muscles and nerves not receive nourishment that they need for repair, but the removal of metabolites from normal muscle functioning is also restricted. Edema of surrounding tissues can result, which increases pressure and tension in the area. Many RSI problems occur in a cycle of tension, restriction of blood flow, edema, and consequent further restriction of movement, that eventually leads to severe problems. Muscle-tension producing RSI problems may be due to repetitive movement, or may be a somato-emotional event that results from psychological stress. In my experience, bodywork of any kind is of minimal help in directly reducing symptoms once the nerve has been injured and full-blown CTS has developed. However, in the long cycle of micro-injury that produces symptoms of RSI, bodywork can be of great help in reducing tension and edema, increasing blood flow, and encouraging different movement that may reduce or reverse RSI symptoms.

Rolfing® can be especially well-suited for this kind of work, because of its emphasis on altering the patterns of movement and strain in the entire body, as contrasted with working only for symptom relief. Rolfers are trained to consider the whole body in looking for an overall pattern of tension or restriction in movement, of which the complaint -RSI or some other condition- is one manifestation. Thinking about the anatomy of, for example, the upper limb illustrates the sense of this. In the hand, while there are numerous muscles that facilitate finger movements that are intrinsic to the hand (having origins and insertions only in the metacarpal and/or phalangeal bones), the flexors and extensors of the digits and wrist have their origins either in the bones of the forearm or the arm. The structural relationship of the forearm to the arm is of course affected by the muscles which cross the elbow. Now we can see a relationship between the muscles of the wrist and those of the arm. Of course the action of the muscles of the arm is also affected by the position of the arm in its socket, which relates to the muscles which have origins in the scapula. And their function is affected by muscles that span between scapula and torso. (Those readers familiar with Tom Myers' explanation of the "anatomy trains" in the body will recognize a similar sequence here.)

From another point of view, tracing the path of the nerve supply to the wrist and hand through this overlapping complex of muscles back to the origins of the brachial plexus in the neck will demonstrate that compression of the median nerve (or radial or ulnar nerve) may occur at any point in its length. To the eye of the Rolfer, a complaint of pain in the hand or wrist may have an origin anywhere along this path.

In addition, the manner in which a Rolfer palpates and gathers information from the body, through the web of fascia, can lead her to feel connections related to the complaint, but perhaps distant from it. Two points are important in this: the connectivity of the tissue, and the layering of tissue in the body.

Western anatomical studies emphasize the separation of muscles and tissues, and we are prone to think of the body as being composed of separate "parts," stuck together in some mysterious way. However, fascia is a continuous web throughout the body, and it is possible to feel the connection between distant restrictions through it. If a Rolfer or other bodyworker, instead of addressing a "tight muscle", can experience the corresponding patterns of tension in the fascia, whole patterns of concurrent strain throughout the body will present themselves. Similarly, the concept of working in the fascial web allows distinctions within muscles, which appear in the concept of layers. Since fascia surrounds not only the gross structures of muscles, organs and bones but also muscle bundles, fasciculi and even individual muscle cells, it is possible to develop a very refined approach to working at "layers" of tissue. The body can be experienced tactilely not only as a collection of muscles, but as infinite layers of connective tissue, any one of which will contain not only muscle fibers, but also portions of other fascially-encased structures. It's not unusual to find restrictions at a particular layer within the limb that may not be present at other layers. For instance, the surface muscle tissue of the wrist flexors may appear quite soft, easily compressible to the touch, but hard at a deeper level. What we think of as "a muscle" that we could dissect from the arm often has differences in consistency within it. It is in layers of tissue that the consistency is felt.

It was my background as a Rolfer, in looking for overall patterns in the body, and in experiencing the body in fascial layers, that allowed me to make some connections between different phenomena that I observed in the people I worked with at Starkey Labs. While many people had pain and numbness of the hand or fingers that we associate with RSI, those people had many different kinds of jobs. Some were office workers who used computer keyboards, but most were technical workers who jobs involved manipulating small objects by hand or with tweezers, gripping small objects while grinding or sanding surfaces, which added vibration to the objects, kneading or squeezing compressible material, or constantly moving the hand between pronation and supination within a small range of movement. In addition, many of these jobs required that the worker sit in a confined posture, including consistent gazing into a microscope.

As a result of these different factors, I found the following conditions also involved in complaints that qualified as RSI syndromes:

• tension in the cubital and proximal flexor compartment, associated with continuous flexion of the elbow and sometimes associated with repeated movement between pronation and supination. I considered this to be overworking of the biceps muscle, especially irritation of the distal tendon, from continual small movements.

  From the viewpoint of considering the fascia, disturbances or stresses within fascial structures may also be important factors in RSI. Tension can be created in the fascia of the flexor compartment because of the attachment of the distal biceps tendon. Besides attaching directly to the radius, it also spreads out into the flexor fascia in an aponeurosis. If we consider that tension in the fascia can create stress on muscles, it is possible that tension in the biceps attachment can produce tension in the fascia to which it is attached; this may contribute to tension in the overall flexor compartment

• Restriction of supination Most work with the hands is done from a pronated position. One of the observations of Rolfing® is that when a particular position is maintained, so that muscles have a repetitive pattern of contraction, surrounding fascia changes to support the muscle contraction. It often becoming inflexible so that the muscle is unable to return to a lengthened resting state. In the case of repetive motion of the hands and arms, this shortening in the pronators of the forearm leads to a condition where the forearm, even when "relaxed", is always in partial pronation. This can easily be seen when a person is lying supine, with the arms at the sides, and the forearm rests with the thumb pointing toward the vertical, rather than laterally.

  A further problem with this condition is that when the forearm is pronated or partially pronated, the interosseous space is compressed, and in pronation the wrist and finger flexor muscles are also compressed. Since the median nerve lies deep in the tissue of these muscles, this kind of squeezing may create additional pressure on the nerve proximal to the carpal tunnel. As the muscle shortening impedes the ability of the forearm to fully supinate, continual contraction of the interosseous fibers also impedes their ability to fully extend and allow the arm to come into supination. A technique to work with this will be discussed below.

• Over-contraction of the opponens and flexor pollicis; contraction of the palmar fascia, particularly at the retinaculum of the wrist; and compression of the carpal joints, particularly the trapezium-scaphoid

The fascia of these intrinsic muscles of the hands is continuous with the thicker fascia that forms the roof of the carpal tunnel, the retinaculum of the wrist. As with the condition of tension in the bicipital aponeurosis in the forearm, continuous tension in the muscle contributes to inelasticity in the retinaculum, as well as an actual narrowing of the space of the carpal tunnel.

We don't usually consider the mobility of the carpal bones as a factor in repetitive strain, since their mobility is relatively limited. However, the gliding joints between these small bones provide the flexion, extension, and rotational movement of the wrist. When movement in the wrist is limited, and muscles and fascia begin to lose their elasticity, this gliding property of the joints can be lost, as their surfaces jam and fluidity in the joint is lost. It is also important to remember that the bones of the wrist form the "floor" of the carpal tunnel. We generally think of trauma in this area resulting from compression within the tunnel by inflammation of tendons; it is a bit of a leap to consider that restriction in the "roof" of the tunnel, the retinaculum, may also be a factor. It's an even bigger leap to think that restriction in the "floor" might also be a problem, but I believe that, at the very least, mobility in the wrist bones helps with the problem of fluid movement in this area, which can help diminish inflammation and edema, precursors to more serious repetitive strain problems.

• Tension in thumb extensors, sometimes resulting in pressure on the radial nerve.

  This was an unusual condition, only appearing in people whose jobs demanded repetitive use of a wide, rather than a narrow grip. Presenting complaints were numbness in the wrist and hand, but on the dorsal side. Obviously, this would indicate some difficulty with the radial nerve supply, rather than the medial or ulnar nerves. The problem, again, was often in compression of the fascial structures associated with tendons, in this case the tendons of the extensor pollicis muscles. The dorsal surface of the forearm would often have a peculiar flattening of the tissue approximately two inches above the wrist, where these muscles would be in continuous contraction.

• Tension in the neck and shoulders, and anterior movement of the scapula on the rib cage.

  Neck and shoulder tension in our society is so common we seldom think of it as anything other than just a condition of living. However, whenever I found another condition of muscle tension that seemed to be a precursor to serious RSI problems, I always found neck and shoulder tension. For the majority of people I worked with, this kind of tension was exacerbated by their working position, which demanded close work with the head inclined forward. While it is possible for typists to alter the position of their keyboard and computer monitors, it was not, at least initially, possible for people who worked with microscopes to do so. Over the course of the years that I worked at Starkey, however, various changes were made in the microscope mounting systems that allowed workers to maintain a more upright posture.

Before these changes were made, working to relieve tension in the neck and shoulder girdle was critical. When you consider that the roots of the nerves in the arms and hands are in the lower cervical vertebrae, it's easy to see why it's important to have free movement and release of muscle tension in the neck. I also found that it was important to work with restrictions in the shoulder girdle. Continuous forward inclination of the head compresses the upper ribs, often shortening pectoralis minor and encouraging the scapula to slide forward on the rib cage. This increases the chances of compression of the brachial plexus near its origin site.

The scope of this article doesn't permit me to address in detail all of the ways I worked with all of these conditions. However, I would like to give one example of how the perspective of Rolfing® allowed me to work with, as well as speculate about, such conditions. For my example, I choose the problem of incomplete supination.

The approach that I took was based on two precepts that I hold in Rolfing:

1) movement allows for both release and re-education; manipulation with movement is more effective than manipulation alone, and

2) using the idea of planes of fascia, we can access deep structures indirectly by working anywhere in the plane of the deep structures.

When the forearm doesn't completely supinate, I consider both the lack of complete relaxation in the pronators, and the probable tension in the interosseous membrane. It seems inefficient to try to affect the interosseous membrane by direct pressure through the muscle tissue of the forearm. However, one can access tissue deep to the flexor compartment by sliding under the edge of the flexor compartment along the medial ulnar shaft. If the client slowly pronates and supinates the forearm while I continue to direct pressure along this plane between the flexor compartment and the bone, a deep release can be felt. Additionally, relatively light pressure can also be directed across the body of the pronator teres, which allows that muscle to come to more complete relaxation when it is not being actively used.

I generally will have my client move into pronation at the start of the movement, then slightly increase pressure as the movement goes toward supination. An increase in intensity of the preferred position at the beginning of the movement allows a greater contrast to the feeling of supination, and as the movement is repeated with the practitioner's hands working with the tissue, the sensation of movement and the contrast between pronation and supination act to educate the neuro-myofascial system into a new balance. Just a few repetitions of movement will bring about a significant increase in the movement of supination.

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