Dear Leslie,
You asked my opinion of Paul Grilley’s article in My Yoga Mentor October 2005. Repetitive strain injury (RSI) is a vast topic. Misinformation about it abounds; indeed, very few doctors are knowledgeable in this area. Most people have no idea just how debilitating RSI can be, and all too often those who want to help unwittingly steer the injured in the wrong direction. My response follows, but obviously there is much crucial information I’ll have to leave out here. Omissions are covered in ample detail in my books and website,rsihelp.com .
I am a big fan of Paul Grilley, and thought his piece on tension or compression, posted on e-Sutra January 4, 2005, had much to commend it. But as the author of two books on RSI, and having helped countless people cope with this disease over the past 15 years, my approach to teaching Yoga to injured people differs quite markedly from his. Yoga, if expertly modified for the student’s injury, can be enormously helpful for people with RSI; however, the wrong asana practice could make matters significantly worse. More on that later.

First, a little background: RSI is a highly complex soft-tissue disease. It is not just one thing, such as carpal tunnel syndrome, as most people assume. Depending on how you count them, RSI comprises about two dozen separate diagnoses to the nerves, tendons and muscles of the upper extremity (from shoulder blade to fingertip), including the best-known (but not the most common) carpal tunnel syndrome, epicondylitis (tennis elbow), thoracic outlet syndrome, De Quervains’ disease, and several nerve entrapments. A new syndrome, “Blackberry Thumb,” was recently reported by the American Society of Hand Therapists. People usually have at least three separate diagnoses and often have as many as two dozen. Also, since each person presents with a unique – and changing – cluster of symptoms, and the severity of injury varies from person to person and day to day, across-the-board protocols do not work for every body.

Unlike many other injuries, RSI is invisible. Without an astute awareness of telltale pain behavior, it is only through the student’s self-disclosure or difficulty in movement that the teacher would know someone has it. Otherwise, they look normal. This can lead teachers to greatly overestimate a student’s capacity.
RSI can be devastating. Not only can it end careers, it can also make common daily activities such as driving, dressing or eating difficult or impossible. Simple things like signing a check, holding a coffee mug or pressing an elevator button can be extremely daunting.

Because of the unforgiving nature of soft-tissue injuries, it’s extremely easy to re-injure yourself if you have RSI, and relapses can be worse than the initial injury. Therefore, I typically see students one-on-one to begin with so they have my undivided attention – and receive a practice tailored to their unique needs. First, I take a thorough health history so I have a general idea of which movements to avoid. We begin with relaxation, so the student can sense breath and learn to guide and be guided by it. I emphasize that the student is in charge, and say, “If something doesn’t feel right for any reason, stop. Don’t do anything that bothers you.” Once the student has established trust in his inner teacher, we can safely proceed to moving at a slow, comfortable pace. I demonstrate postures before we do them for the first time, and ask the student if he thinks that asana would bother him before we proceed. I also watch students’ facial expressions, quality of movement and breathing, and stop them immediately if there is any sign of struggle or strain.
My approach also differs from Grilley’s in emphasis: his exercises focused on stretching. While this is very important, my program emphasizes strengthening as well. People often develop RSI because of weakness, particularly in the back muscles, so I design practices that bring balance to the muscles, strengthening and stretching them.

Regarding the specifics of Grilley’s piece, I’ll respond point by point. Let’s begin with the dinner-plate analogy. In fact, most computer users do not position their arms as though holding a dinner plate. Rather, they rest their wrists on the edge of the desk because the shoulder muscles become extremely fatigued from holding the weight of the arm. Fatigue also leads to the forward head and slouched posture common among computer users. To compound the risk factors, the keyboard is often on the desk, rather than an appropriately lowered keyboard tray. This leads to more shoulder strain as the computer user constantly lifts her shoulders as she keys or reaches for the mouse. Wrist-resting leads to a multitude of possible problems: the compression of the median nerve at the wrist; and the dorsiflexion (upward bend) and ulnar deviation (sideways bend) of the wrist, both of which can strain the forearm tendons, muscles and nerves.
Grilley correctly states that computer users need movement, but the single most important – and most difficult – step toward rehabilitating RSI is neither movement nor stillness per se, but ceasing to use the computer or stopping any other offending activity. Given that most people’s jobs involve computer use, this is a thorny and frightening dilemma.
Grilley’s suggestions for movement at work may seem innocuous, but when you deal with RSI, you quickly learn that the simplest exercise or movement could be too much for someone.

• Dropping your arms by your side can be very fatiguing to people with shoulder injuries or cause unpleasant tingling in people who have thoracic outlet syndrome. My suggestion: rest your forearms palms up on a big pillow or two placed on your lap – this rests the shoulders and relieves the forearms from the strain of pronation (the palms-down position).
• Many people cannot stretch their arms overhead without difficulty; and any relief from symptoms would be fleeting at best if they have chronic pain.
• Pushups, one of the exercises Grilley mentioned, are contraindicated for people with RSI because most cannot bear any weight through the wrist.
My approach is to tell uninjured people that they need regular breaks from computing, at least one 5-10 minute break for every twenty minutes at the keyboard. Most authors of articles on RSI and ergonomics offer exercises you can do seated at your desk, but because sitting in and of itself is a prime risk factor for RSI, I urge people to do what the body was designed for – full-body movement. To that end, I encourage people to get up from their chairs and go for a walk to stimulate circulation, and rest their eyes by gazing in the distance, preferably out a window. For more on why breaks are so important, see http://rsihelp.com/breaks_important.shtml.

Grilley was quite right to caution mindfulness with his suggested exercises, but, with the exception of the second exercise (gently dropping the head forward), I would not recommend any of his choices. His suggestions would be fine for experienced Yogis with ample range of motion and strength, but many people come to Yoga only after they are severely injured, and they may not have exercised for years. Most of his examples too extreme for such beginners, and could lead to more pain and injury.
• In his first exercise, bending the head back would be very painful for people with limited range of motion or severe neck pain. Here’s one alternative choice: keeping your gaze on a fixed point straight ahead, make a slow figure eight with your nose in an easy range of motion, avoiding extreme upward movement of the head.
• In the Eagle variation, few of my students with RSI would be capable of sitting on the floor with straight legs and resting their elbows on the floor or even a bolster without rounding – hence straining – their backs. Doing this pose on a hard surface such as a desk could be damaging to the ulnar nerve, which is already stretched to maximum length. (By the way, habitually leaning on your elbow on hard surfaces is one of the ways people develop ulnar nerve injuries.)
• I strongly caution people with RSI to avoid the Broken Wing variation. While this pose might feel marvelous to an uninjured person, if someone has rotator cuff tendinitis, for instance, they cannot reach into a back hip pocket or unhook a bra without pain, much less place their hand between their shoulder blades – then rest their body weight on top of that! I’ve also had students who could barely bend their elbows because of pain. Placing the body weight on an injured forearm could likely set off an episode of pain or tingling.
• As for the Peacock variation, because so few people with RSI are comfortable in Cat pose, this extra-strong forearm stretch would be entirely too much for most of them. A safer choice would be a simple Namaste, going only as far as is easy, or gently circling the wrists. Later, when the student has gained flexibility, I prefer a standing variation of the pose my teacher, Kevin Kortan, showed me: place your hands on the wall for support so the body weight is more easily controlled. In this position you can ease into the pose slowly and back off quickly if it’s too much.

Given Paul Grilley’s statements about “freeing ourselves from the tyranny of ‘proper form’ and ‘perfect poses,’ I feel confident that he would not intentionally encourage someone with RSI to strain. I also applaud him for caring enough to bring this topic to light. RSI is the leading occupational disease in the United States – and people’s lives are devastated by it every day – but RSI prevention has received less and less government support since the Bush administration vetoed the Occupational Safety and Health Administration (OSHA) ergonomic standard. The leading cause of RSI is ignorance. No one who uses a computer should find out about RSI the hard way by becoming injured. And no one who comes to Yoga seeking help should be further injured in the attempt to heal.

– Deborah Quilter

Deborah Quilter is the author of The Repetitive Strain Injury Recovery Book (Walker, New York 1998) and what Amazon.com called the “bible” of RSI: Repetitive Strain Injury: A Computer User’s Guide (with Emil Pascarelli, M.D., Wiley, New York 1994). She has spoken internationally on RSI and appears in the media frequently. She earned her yoga teacher certification through Spanda®: the Yoga of Movement, and holds certifications in personal fitness training from Marymount Manhattan College and the American Council on Exercise. Ms. Quilter studies Evolutionary Yoga™ with its founder, Kevin Kortan. She is writing another series of books and articles about RSI, and will also be teaching other Yoga teachers her methods for helping students do asana without exacerbating existing injuries at Kripalu and other venues including the Breathing Project next year. For more information, visit her website, rsihelp.com.