Research projects completed and awaiting publication:

1. Sharan D, Jacob BN, Ajeesh PS, Barathur R, Bookout J. The Effect of Cetylated Fatty Esters and Physical Therapy on Myofascial Pain Syndrome of the Neck. Phase 4 Randomised Controlled Trial (over 100 patients). In final stages of review for publication in European Journal of Pain.
2. Sharan D, Jacob BN, Ajeesh PS. Myofascial pain syndrome: A cause of post injection limping in children.
   
3. Sharan D, Ajeesh PS, Jacob BN, Kumar R. Risk Factors, Clinical Features and Outcome of Treatment of Work Related Musculoskeletal Disorders in onsite clinics in Indian IT Companies.
4. Sharan D, Kumar R, Jacob BN, Ajeesh PS. Musculoskeletal disorders in Caregivers of Children with Cerebral Palsy following Multilevel Surgery.
5. Sharan D, Babu M, Jacob BN, Ajeesh PS. Effectiveness of a sequenced rehabilitation protocol for thoracic outlet syndrome in computer professionals
6. Sharan D, Kumar R, Jacob BN, Ajeesh PS. Description and outcome of treatment of a new triad of anterolateral knee pain and movement dysfunction

The following research projects are under way at RECOUP and are scheduled to be completed in 2009

         
Current Research

 I am leading the largest prospective study in the world on Computer Related Repetitive Strain Injury (RSI). This comprehensive, prospective study started on February 8, 2001 and will be completed in 2008. Our aim is to study over 35,000 computer professionals to determine the prevalence, predisposing factors, presenting features and outcome of treatment of RSI.

The following material is a part of my paper titled "Computer Related Injuries: The Indian Experience", presented on November 15, 2002, during the AA Mehta Gold Medal Session of the 47th Annual Conference of the Indian Orthopaedic Association. The number of computer users studied has since extended to over 35,000 and over 80 IT/ITES Professionals have now lost their jobs.

Study Population

• 650 subjects in computer-dependent careers
• Recreational users were excluded from this particular study, though our youngest RSI patient was aged 5.

Presenting Symptoms                                                                                                                 Top

• Back pain (47%), Neck pain (35%), Shoulder pain (34%), Hand/wrist pain (26%), Arm pain (22%), Visual strain (20%), Anterior knee pain (20%), Tingling/numbness of hand (16%), Weakness of hand (10%), Pilot Seat Syndrome (10%)

• 76% of those surveyed reported having at least one musculoskeletal symptom
• Median age 27 years (range: 18 to 52). In most studies reported from the west the commonest age group is 40-50 years.
• 55% developed symptoms within 1 year of starting computer dependent careers, clearly demonstrating that most Indian Computer Users are unaware of safe computing techniques.
• 60% of those with severe disorders (neurovascular compression or tendinitis) recalled having chronic neck and shoulder pain or stiffness that they had considered "normal" for computer users and ignored

Predisposing Ergonomic Factors
Lack of appropriate breaks (86%), Improper monitor height (60%), Mouse too high (54%), Resting the arm or wrist on a hard surface while typing (42%), Keyboard too high (40%), Bizarre leg positioning (25%)

Predisposing Postural Factors
Head forward (92%), Rounded back (75%), Protracted shoulders (55%)

Specific Physical Findings

Past Treatment (n = 353)                                                                                                                            Top

• 65% (mis)diagnosed as "spondylitis", "arthritis", "slipped disc", "tennis elbow", "muscle sprain" or "Carpal Tunnel Syndrome"
• 20% diagnosed as RSI but told "RSI is incurable" or given steroids (cortisone), Vitamin B12 injections or Antidepressants
• 30% had x-rays/bloods (useless in establishing diagnosis)
• 15% had MRI's (all essentially normal!)
• 10% had Nerve Conduction Studies (all abnormal!, but non-contributory in management)
• 0% had an on-site workstation evaluation
• 100% had failed conventional Physiotherapy (e.g., traction, short-wave diathermy, infra-red, ultrasound, IFT, isometric exercises)

Predisposing Medical Disorders

• 10 (0.02%) had a pre-existing medical condition or surgical history.
• 5 (0.01%) had an anatomical predisposition (e.g., Cervical Ribs)
• 32% admitted significant stress at home/work
• 80% led sedentary lifestyles

Speed of Recovery

• Related to the stage at presentation, with little correlation to duration of symptoms
• Stages of RSI (Damany & Bellis, 2001): Patients who presented at an earlier stage (stage 1: pain during work, that eased off as soon as you stopped working) almost always got better within a few days or weeks. Stage 2 (pain that went home with you, and interfered with your regular activities, but disappeared by morning) usually took a few months to improve. Stage 3 (pain that woke you up, and stayed with you all day and night) was much more difficult to treat and took several months.

The bad news

• 6 Software Engineers (25-35 year old) had to give up Computer-dependent careers due to advanced RSI symptoms
• 85% of the respondents were from the so-called blue-chip IT Companies. One shudders to think what would be the situation in lesser equipped IT Companies, banks, newspaper offices, and colleges/training institutes.

Message                                                                                                                                                        Top

• The high incidence of RSI in India is remarkable because no financial gain is involved, unlike in the west. Only "genuine" patients* would report symptoms here. In fact, there are huge disincentives to report symptoms (lack of support from management, possibility of retrenchment, etc.)
• RSI is a diffuse neuromuscular disorder: a physical problem, not a psychosomatic one (though stress may aggravate symptoms)
• There are significant proximal upper body findings that affect distal function. In other words, pain or numbness in the hand may signify a neuro-vascular compression in the neck.
• The best-known RSI, Carpal Tunnel Syndrome, is actually very rare in India
• Splints, Conventional Physiotherapy, Medicines of all systems, and Surgery frequently made matters worse
• All affected individuals had significant postural and/or ergonomic abnormailities that needed correction

* This is not to say that RSI patients in other countries are malingerers!

Causes of RSI?
RSI arises due to the following factors:

• Prolonged repetitive, forceful, or awkward hand movements
• Poor posture
• "Static loading" or holding a posture which promotes muscle tension for a long period
• Poor conditioning of the heart and lungs, and poor muscle endurance
• Direct mechanical pressure on tissues
• Cold work environment
• Poorly fitting furniture
• Basic inadequacies of keyboard, monitor and workstation design
• Work organisational and psychosocial issues

Our findings are identical to that of similar research being carried out by Dr. Emil Pascarelli at Columbia University in USA, who is considered one of the foremost expert in the world on RSI. Double Crush Syndrome is common in RSI: there may be compression or injury at multiple points during the course of a nerve, from the neck down to the hand. What was earlier passed off as Carpal Tunnel Syndrome (nerve compression in the wrist) is now increasingly recognised as being due to neurovascular compression in the neck. This finding has far-reaching consequences on the treatment of RSI. Nerve surgery at wrist or elbow would be a disaster in such cases and no amount of physiotherapy at the wrist/hand would help because the problem usually lies higher up. 

Recommendations                                                                                                                                      Top

• Awareness programmes for employees, employers, school and college teachers, and medical professionals
• Mandatory practical training and certification on safe computing techniques, body awareness and posture for all computer users
• Early Intervention for RSI symptoms. Neck and shoulder discomfort should never be ignored.
• Reporting, referral (for treatment) and workplace accomodation procedures in organisations

Food for thought
What will be the prevalence of RSI in India when the present lot of children who have been ab(using) computers and suffering backpack and postural injuries since the age of 3 grow up to be IT Professionals?

Who'll bell the cat?                                                                                                                                  Top
NASSCOM?, IT Companies?, Individual Computer Users?, Doctors?, Parents?, Teachers?, Government?

Significant effort needs to be made by each group, in a coordinated manner. A reasonable start would be for NASSCOM to fund a comprehensive multi-centre study to estimate the magnitude of the problem, predisposing factors, with an eye on the steps necessary for prevention. I have emailed Mr. Kiran Karnik, President, NASSCOM, in 2003 about the seriousness of the problem, without eliciting as much as an acknowledgement from him.

The pattern and nature of RSI in India is significantly different from that in the western countries. There are significant anthropological differences in the body shape and dimensions, work practices, and furniture design. These problems are unique to our country and so should be the solutions.