Look, Ma, no hands! Coping with Repetitive Strain Injury

Harris RSI -- LISA '99 1

Trey HarrisMail.comtharris@staff.mail.comhttp://metalab.unc.edu/~harris/rsi

A disclaimer I’m not a medical practitioner This talk is for informational

purposes only, and is not intended to diagnose or treat any illness or disease

Follow my suggestions at your own risk

Myth #1 “I don’t type a lot, so I can’t

get RSI.”

Myth #1 “I don’t type a lot, so I can’t

get RSI.” Fact: Anyone who types more

than two hours a day is at risk for RSI

Myth #2 RSI is mostly psychosomatic

Myth #2 RSI is mostly psychosomatic Fact: Though usually invisible,

RSI is a soft tissue injury susceptible to medical diagnosis and treatment

Myth #3 “I don’t touch type, so I can’t

get RSI.”

Myth #3 “I don’t touch type, so I can’t

get RSI.” Fact: though hunt-and-peckers

are less likely to develop RSI, certain habits (such as holding up the thumbs or making a fist while typing) can cause serious ailments

Myth #4 Carpal tunnel syndrome is the

most common kind of RSI

Myth #4 Carpal tunnel syndrome is the

most common kind of RSI Fact: CTS is actually one of the

rarest forms of RSI, and its over-diagnosis and over-hyping can be a barrier to effective treatment for RSI patients

Myth #5 “My symptoms have been like

this for years, so I guess it won’t get any worse.”

Myth #5 “My symptoms have been like

this for years, so I guess it won’t get any worse.”

Fact: RSI is progressive, and even if the pain doesn’t get worse, permanent disability is possible if the injury gets bad enough

Myth #6 “If my hands get really bad, I

can always switch to voice dictation until it gets better.”

Myth #6 “If my hands get really bad, I

can always switch to voice dictation until it gets better.”

Fact: Current voice dictation systems are a poor substitute for the keyboard, especially for technical workers

My story Binge typing Poor posture and awful

ergonomics Years of incremental

adjustments Denial Finally, a scare

A week of terror inability to type excruciating pain soreness and heaviness clumsiness hyperawareness & an “injured

feeling”

I’m going to fix this! Appt. w/doctor Braces Voice dictation

Down and dirty with dictation Training

and frustration I don’t do Windows!

more frustration How do you pronounce “s/^\

S+([^:])*/$1.old/”? even more frustration

A demonstration Dragon NaturallySpeaking

Professional Only available from certain

consulting vendors Teen, Standard or Preferred won’t

work “conversational” speech system

This laptop 300 MHz Intel Celeron 96MB RAM

How it’ll work (It’s going to be excruciating)

Troubles in voice-land Passwords? Curses/cbreak programs are

dangerous Many GUIs don’t work well with

speech The command line is doable, but hard X is near impossible Errors Discrete systems are better except

when they’re worse Laryngitis is an RSI

A disturbing prognosis Diagnostics

The Poking Test The Prodding Test The Shocking Test The Numbing Test

So what is it, anyway? Treatment: braces -- and

maybe surgery Did you say permanent???

A friend steps in Pascarelli & Quilter, Repetitive

Strain Injury (John Wiley & Sons, 1994)

I do a lot of self-education

What is RSI? Repetitive Strain Injury RSI != Carpal Tunnel Syndrome Umbrella term for Cumulative

Trauma Disorders (CTD) stemming from hand movements that are: prolonged repetitive forceful awkward

What does RSI affect? Involves damage to:

muscles tendons nerves

In the areas of: neck shoulder arms hand

What does RSI feel like? Great variability between sufferers,

but commonly reported symptoms include: Pain

acute (stabbing) or chronic (soreness)

shooting or localized brief or long-lasting

Weakness Numbness or other neurological

symptoms (referred pain, etc.) Motor impairment (clumsiness, etc.)

Warning signs of RSI Pain during typing Difficulty with ordinary chores Opening doors with shoulders or feet Stiffness, weakness, or lack of

endurance Heaviness Lack of coordination, dropping things Cold hands Hyperawareness of hands Frequent self-massage or “cracking”

Causes of RSI Repetition Ignorance of proper use of the

hand Poor posture Holding still Being out of shape Forced speed Overwork Excessive monitoring Lack of job satisfaction

RSI isn’t a fracture RSI is a soft tissue injury, so:

it comes on very slowly it takes a long time to heal rest alone will not affect recovery it rarely comes back to 100% relapses are par for the course endurance is the last thing to return symptoms poorly differentiate—a

successful treatment of one ailment often reveals other undiscovered ones

Types of RSI Muscle & tendon disorders Cervical radiculopathy Epicondylitis & ganglion cysts Tunnel syndromes Nerve & circulatory disorders Other associated disorders

Muscle & tendon disorders Muscle and tendon disorders

Myofascial damage Tenosynovitis Stenosing tenosynovitis

DeQuervain’s disease Flexor tenosynovitis (trigger

finger)

Tendinitis Shoulder tendinitis

Bicipital tendinitis Rotator cuff tendinitis

Forearm tendinitis Flexor carpi radialis tendinitis Extensor tendinitis Flexor tendinitis

Cervical radiculopathy “phone shoulder syndrome”

Epicondylitis & ganglion cysts Epicondylitis

lateral (tennis elbow, bowler’s elbow, pitcher’s elbow)

medial (golfer’s elbow) Ganglion cysts (“bible bumps”)

Tunnel syndromes & CTS Tunnel syndromes involve three

nerves: median (middle) radial (thumb side) ulnar (pinkie side)

Median nerve -- Carpal Tunnel Syndrome Dynamic (RSI) Passive (rheumatoid arthritis,

gout, diabetes, hypothyroidism, etc.)

CTS is rare Carpal tunnel syndrome is one

of the rarest forms of RSI 15% of office workers have

some form of RSI < 1% have CTS

So why is it so prevalent in discussion? Obvious treatment options Medically less controversial Profitable for surgeons

Radial and ulnar tunnel syndromes Radial Tunnel Syndrome Ulnar Nerve Disorders

Sulcus Ulnaris Syndrome Cubital Tunnel Syndrome Guyon’s Canal Syndrome

Nerve & circulatory disorders Thoracic Outlet Syndrome Raynaud’s Phenomenon

Other associated disorders Reflex Sympathetic

Dysfunction or Dystrophy (RSD)

Focal Dystonia (writer’s cramp)

Osteoarthritis Fibromyalgia Dupuytren’s Contracture

I take control Get rid of the braces Insist on a better diagnosis Abort the path towards

surgery Start aggressive physical

therapy and bodywork

The traditional medical team General, family or adult practitioner Physical therapist(s) Specialists:

Orthopedist Hand surgeon Neurologist Occupational/sports medicine

doctor Physiatrist Rheumatologist

Pain management specialist

The alternative medical team Massage therapist(s)

neuromuscular therapy Swedish or shiatsu Rolfing or Hellerwork Feldenkrais

Osteopath or chiropractor Acupuncturist Naturopath Yoga instructor

Medication Non-steroidal anti-

inflammatories (NSAIDs) ibuprofen or fenoprofen Butazolidin, Indocin, Voltaren

Pain medication OTC: aspirin, acetaminophen Painkillers: codeine, Perkocet,

hydrocodone Cortisone

Splinting Splints are controversial Often indicated for CTS or

DeQuervain’s syndrome NEVER use them while

typing!!! “Braces” aren’t much better

Surgery Is it really necessary? Is surgery efficacious for this

condition? Have all nonoperative

techniques been eliminated? Is it a quick fix? Get a second opinion (and a

third, and a fourth…)

Physical Therapy Deep-tissue massage Phonophoresis Iontophoresis Ultrasound Transcutaneous electrical

nerve stimulation (TENS) Upper body exerciser (UBE)

machine Neuromuscular stretches

Occupational Therapy Work hardening is a no-no for

RSI Posture retraining Preventative exercise

Stretching Strengthening

Alternative therapies Acupuncture Spinal manipulation Massage therapy Vitamins Yoga

What not to do Don’t self-diagnose! Don’t exercise without the advice

and consent of your practitioner Don’t rush to surgery Don’t look for an easy way out Don’t let your doctor talk you

into treatment options you don’t want

Don’t fall for “ergonomic” gimmicks

Your recovery Stop (or at least reduce) the

injurious behavior See a doctor trained in soft-tissue

injuries Start medical treatment Investigate alternative care, if

appropriate Develop new long-term work and

living habits Develop a maintenance plan

(exercise and massage)

First step: stop hurting yourself Take a break Take the day off Take vacation Take disability leave Take unemployment Whatever it takes -- don’t let

RSI become something worse Permanent disability can set in

within weeks or months if you don’t do something now

But is it really that serious? It is, if you experience any of the

following: Pain

bad enough to bring tears that doesn’t go away with a break,

that you go to bed with, or wake up with

that wakes you up at night that changes your daily routine

Neurological symptoms Clumsiness, or an “out of control”

feeling Numbness or paralysis

Rest Refers to the temporary

cessation of injurious behavior, not to stopping activity with the injured part entirely

Gentle motion is necessary Therapy begins during the rest

period

Patience! RSI takes a long time to heal Endurance is the last thing to

return Keep a log

Living and coping Reduce and improve overall

hand and arm use, not just typing

Take frequent breaks Pay attention to the signals

your body is giving you

I learn to live Services, services, services! You don’t look injured…. The bag, the book, and the

handshake Dealing with doors Flex those schedules!

Prioritize What uses of your hands are

really important to you? Work Household chores Driving Recreation

Find ways to eliminate or reduce the less important ones

Dealing with flare-ups Ice Heat Frequent breaks Stretches

Ergonomics 101 Goal: free, effortless movement of

body Everyone is different The injurious positions:

pronation ulnar deviation dorsiflexion

Tense, constrained movements are never good, no matter how “correct”

Even the best positioning needs to be changed frequently

Ergonomics 101 Get your chair up! Get your keyboard down! Put down those kickstands! Get rid of your wrist rest (for

awhile) Keyboards are bad Mice are worse Trackballs are awful Adjustability is essential

The keyboard Fancy keyboards aren’t always

the best

Ergonomic keyboards

Comfort Keyboard too adjustable?

Ergonomic keyboards

Microsoft Natural Not adjustable Requires

radial deviation

Forward tilt is good

Ergonomic keyboards IBM Options

separate pieces allow for infinite adjustability

but discontinued...

The mouse An ergonomic nightmare Options to think about

Cordless mouse New Microsoft Intellimouse

Avoid using the mouse whenever you can

Alternate pointing devices Trackballs are bad Graphic tablets are pretty

good Avoid pronation, dorsiflexion

and ulnar deviation

An example of bad ergonomics Logitech Trackman Marble FX

What about laptops? You can use a laptop

ergonomically Lighter vs.. bigger keyboard Move around!

Ergonomic furniture 101 The table The chair The keyboard tray

The table Sit/stand stations are the best Flat if you have a keyboard

tray Sectioned if you don’t Easy resetting to presets Does it float?

The chair Height Forward tilt Lumbar support Armrests

The keyboard tray Get one

Evaluate knee clearance Adjust it carefully; for best results,

get an ergonomist to do it for you Non-adjustable trays are

unacceptable and ergonomically the same as a fixed table

If your table is sufficiently adjustable, you can use it instead

Does it hold your mouse too?

The ideal ergonomic setup (IMHO) Good chair Flat sit/stand station Keyboard tray w/mouse pad Graphics tablet LCD screen

Random ergonomic nostrums

Wrist rests Forearm rests Cording

keyboards Weird input

devices

Web sites for more info The Typing Injury FAQ --

www.tifaq.org Deborah Quilter’s

www.rsihelp.com

Slides http://metalab.unc.edu/

~harris/rsi

Look, Ma, no hands! Coping with Repetitive Strain Injury

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