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

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

• Trey Harris
• Mail.com
• tharris_at_staff.mail.com
• http//metalab.unc.edu/harris/rsi

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A disclaimer

• Im 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

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Myth 1

• I dont type a lot, so I cant get RSI.

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Myth 1

• I dont type a lot, so I cant get RSI.
• Fact Anyone who types more than two hours a day
  is at risk for RSI

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Myth 2

• RSI is mostly psychosomatic

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Myth 2

• RSI is mostly psychosomatic
• Fact Though usually invisible, RSI is a soft
  tissue injury susceptible to medical diagnosis
  and treatment

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Myth 3

• I dont touch type, so I cant get RSI.

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Myth 3

• I dont touch type, so I cant 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

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Myth 4

• Carpal tunnel syndrome is the most common kind of
  RSI

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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

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Myth 5

• My symptoms have been like this for years, so I
  guess it wont get any worse.

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Myth 5

• My symptoms have been like this for years, so I
  guess it wont get any worse.
• Fact RSI is progressive, and even if the pain
  doesnt get worse, permanent disability is
  possible if the injury gets bad enough

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Myth 6

• If my hands get really bad, I can always switch
  to voice dictation until it gets better.

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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

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My story

• Binge typing
• Poor posture and awful ergonomics
• Years of incremental adjustments
• Denial
• Finally, a scare

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A week of terror

• inability to type
• excruciating pain
• soreness and heaviness
• clumsiness
• hyperawareness an injured feeling

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Im going to fix this!

• Appt. w/doctor
• Braces
• Voice dictation

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Down and dirty with dictation

• Training
• and frustration
• I dont do Windows!
• more frustration
• How do you pronounce s/\S()/1.old/?
• even more frustration

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A demonstration

• Dragon NaturallySpeaking Professional
• Only available from certain consulting vendors
• Teen, Standard or Preferred wont work
• conversational speech system
• This laptop
• 300 MHz Intel Celeron
• 96MB RAM
• How itll work
• (Its going to be excruciating)

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Troubles in voice-land

• Passwords?
• Curses/cbreak programs are dangerous
• Many GUIs dont work well with speech
• The command line is doable, but hard
• X is near impossible
• Errors
• Discrete systems are better except when theyre
  worse
• Laryngitis is an RSI

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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???

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A friend steps in

• Pascarelli Quilter, Repetitive Strain Injury
  (John Wiley Sons, 1994)
• I do a lot of self-education

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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

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What does RSI affect?

• Involves damage to
• muscles
• tendons
• nerves
• In the areas of
• neck
• shoulder
• arms
• hand

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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.)

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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

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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

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RSI isnt 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 differentiatea successful
  treatment of one ailment often reveals other
  undiscovered ones

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Types of RSI

• Muscle tendon disorders
• Cervical radiculopathy
• Epicondylitis ganglion cysts
• Tunnel syndromes
• Nerve circulatory disorders
• Other associated disorders

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Muscle tendon disorders

• Muscle and tendon disorders
• Myofascial damage
• Tenosynovitis
• Stenosing tenosynovitis
• DeQuervains disease
• Flexor tenosynovitis (trigger finger)

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Tendinitis

• Shoulder tendinitis
• Bicipital tendinitis
• Rotator cuff tendinitis
• Forearm tendinitis
• Flexor carpi radialis tendinitis
• Extensor tendinitis
• Flexor tendinitis

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Cervical radiculopathy

• phone shoulder syndrome

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Epicondylitis ganglion cysts

• Epicondylitis
• lateral (tennis elbow, bowlers elbow, pitchers
  elbow)
• medial (golfers elbow)
• Ganglion cysts (bible bumps)

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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.)

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CTS is rare

• Carpal tunnel syndrome is one of the rarest forms
  of RSI
• 15 of office workers have some form of RSI
• lt 1 have CTS
• So why is it so prevalent in discussion?
• Obvious treatment options
• Medically less controversial
• Profitable for surgeons

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Radial and ulnar tunnel syndromes

• Radial Tunnel Syndrome
• Ulnar Nerve Disorders
• Sulcus Ulnaris Syndrome
• Cubital Tunnel Syndrome
• Guyons Canal Syndrome

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Nerve circulatory disorders

• Thoracic Outlet Syndrome
• Raynauds Phenomenon

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Other associated disorders

• Reflex Sympathetic Dysfunction or Dystrophy (RSD)
• Focal Dystonia (writers cramp)
• Osteoarthritis
• Fibromyalgia
• Dupuytrens Contracture

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I take control

• Get rid of the braces
• Insist on a better diagnosis
• Abort the path towards surgery
• Start aggressive physical therapy and bodywork

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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

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The alternative medical team

• Massage therapist(s)
• neuromuscular therapy
• Swedish or shiatsu
• Rolfing or Hellerwork
• Feldenkrais
• Osteopath or chiropractor
• Acupuncturist
• Naturopath
• Yoga instructor

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Medication

• Non-steroidal anti-inflammatories (NSAIDs)
• ibuprofen or fenoprofen
• Butazolidin, Indocin, Voltaren
• Pain medication
• OTC aspirin, acetaminophen
• Painkillers codeine, Perkocet, hydrocodone
• Cortisone

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Splinting

• Splints are controversial
• Often indicated for CTS or DeQuervains syndrome
• NEVER use them while typing!!!
• Braces arent much better

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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)

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Physical Therapy

• Deep-tissue massage
• Phonophoresis
• Iontophoresis
• Ultrasound
• Transcutaneous electrical nerve stimulation
  (TENS)
• Upper body exerciser (UBE) machine
• Neuromuscular stretches

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Occupational Therapy

• Work hardening is a no-no for RSI
• Posture retraining
• Preventative exercise
• Stretching
• Strengthening

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Alternative therapies

• Acupuncture
• Spinal manipulation
• Massage therapy
• Vitamins
• Yoga

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What not to do

• Dont self-diagnose!
• Dont exercise without the advice and consent of
  your practitioner
• Dont rush to surgery
• Dont look for an easy way out
• Dont let your doctor talk you into treatment
  options you dont want
• Dont fall for ergonomic gimmicks

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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)

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First step stop hurting yourself

• Take a break
• Take the day off
• Take vacation
• Take disability leave
• Take unemployment
• Whatever it takes -- dont let RSI become
  something worse
• Permanent disability can set in within weeks or
  months if you dont do something now

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But is it really that serious?

• It is, if you experience any of the following
• Pain
• bad enough to bring tears
• that doesnt 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

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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

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Patience!

• RSI takes a long time to heal
• Endurance is the last thing to return
• Keep a log

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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

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I learn to live

• Services, services, services!
• You dont look injured.
• The bag, the book, and the handshake
• Dealing with doors
• Flex those schedules!

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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

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Dealing with flare-ups

• Ice
• Heat
• Frequent breaks
• Stretches

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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

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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

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The keyboard

• Fancy keyboards arent always the best

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Ergonomic keyboards

• Comfort Keyboard
• too adjustable?

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Ergonomic keyboards

• Microsoft Natural
• Not adjustable
• Requires radial deviation
• Forward tilt is good

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Ergonomic keyboards

• IBM Options
• separate pieces allow for infinite adjustability
• but discontinued...

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The mouse

• An ergonomic nightmare
• Options to think about
• Cordless mouse
• New Microsoft Intellimouse
• Avoid using the mouse whenever you can

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Alternate pointing devices

• Trackballs are bad
• Graphic tablets are pretty good
• Avoid pronation, dorsiflexion and ulnar deviation

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An example of bad ergonomics

• Logitech Trackman Marble FX

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What about laptops?

• You can use a laptop ergonomically
• Lighter vs.. bigger keyboard
• Move around!

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Ergonomic furniture 101

• The table
• The chair
• The keyboard tray

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The table

• Sit/stand stations are the best
• Flat if you have a keyboard tray
• Sectioned if you dont
• Easy resetting to presets
• Does it float?

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The chair

• Height
• Forward tilt
• Lumbar support
• Armrests

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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?

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The ideal ergonomic setup (IMHO)

• Good chair
• Flat sit/stand station
• Keyboard tray w/mouse pad
• Graphics tablet
• LCD screen

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Random ergonomic nostrums

• Wrist rests
• Forearm rests
• Cording keyboards
• Weird input devices

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Web sites for more info

• The Typing Injury FAQ -- www.tifaq.org
• Deborah Quilters www.rsihelp.com

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Slides

• http//metalab.unc.edu/harris/rsi