Look, Ma, no hands!
Coping with Repetitive Strain
Injury
Trey Harris
Mail.com
tharris@staff.mail.com
http://metalab.unc.edu/~harris/rs
i
Harris RSI -- LISA '99
1
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
Harris RSI -- LISA '99
2
Myth #1

“I don’t type a lot, so I can’t get
RSI.”
Harris RSI -- LISA '99
3
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
Harris RSI -- LISA '99
4
Myth #2

RSI is mostly psychosomatic
Harris RSI -- LISA '99
5
Myth #2


RSI is mostly psychosomatic
Fact: Though usually invisible, RSI
is a soft tissue injury susceptible to
medical diagnosis and treatment
Harris RSI -- LISA '99
6
Myth #3

“I don’t touch type, so I can’t get
RSI.”
Harris RSI -- LISA '99
7
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
Harris RSI -- LISA '99
8
Myth #4

Carpal tunnel syndrome is the
most common kind of RSI
Harris RSI -- LISA '99
9
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 overdiagnosis and over-hyping can be
a barrier to effective treatment for
RSI patients
Harris RSI -- LISA '99
10
Myth #5

“My symptoms have been like this
for years, so I guess it won’t get
any worse.”
Harris RSI -- LISA '99
11
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
Harris RSI -- LISA '99
12
Myth #6

“If my hands get really bad, I can
always switch to voice dictation
until it gets better.”
Harris RSI -- LISA '99
13
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
Harris RSI -- LISA '99
14
My story





Binge typing
Poor posture and awful
ergonomics
Years of incremental adjustments
Denial
Finally, a scare
Harris RSI -- LISA '99
15
A week of terror





inability to type
excruciating pain
soreness and heaviness
clumsiness
hyperawareness & an “injured
feeling”
Harris RSI -- LISA '99
16
I’m going to fix this!



Appt. w/doctor
Braces
Voice dictation
Harris RSI -- LISA '99
17
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
Harris RSI -- LISA '99
18
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
Harriswork
RSI -- LISA '99
19
Troubles in voiceland







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
RSI -- LISA '99
20
when Harris
they’re
worse
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???
Harris RSI -- LISA '99
21
A friend steps in


Pascarelli & Quilter, Repetitive
Strain Injury (John Wiley & Sons,
1994)
I do a lot of self-education
Harris RSI -- LISA '99
22
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
Harris RSI -- LISA '99
23
What does RSI
affect?

Involves damage to:
 muscles
 tendons
 nerves

In the areas of:
 neck
 shoulder
 arms
 hand
Harris RSI -- LISA '99
24
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.)
Harris RSI -- LISA '99
 Motor impairment (clumsiness,
25
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
Harris RSI -- LISA '99
Hyperawareness of hands
26
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
Harris RSI -- LISA '99
27
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
Harris RSI -- LISA '99
undiscovered ones
28
Types of RSI






Muscle & tendon disorders
Cervical radiculopathy
Epicondylitis & ganglion cysts
Tunnel syndromes
Nerve & circulatory disorders
Other associated disorders
Harris RSI -- LISA '99
29
Muscle & tendon
disorders

Muscle and tendon disorders
 Myofascial
damage
 Tenosynovitis
 Stenosing tenosynovitis
 DeQuervain’s
disease
 Flexor tenosynovitis (trigger finger)
Harris RSI -- LISA '99
30
Tendinitis

Shoulder tendinitis
 Bicipital
tendinitis
 Rotator cuff tendinitis

Forearm tendinitis
 Flexor
carpi radialis tendinitis
 Extensor tendinitis
 Flexor tendinitis
Harris RSI -- LISA '99
31
Cervical
radiculopathy

“phone shoulder syndrome”
Harris RSI -- LISA '99
32
Epicondylitis &
ganglion cysts

Epicondylitis
 lateral
(tennis elbow, bowler’s
elbow, pitcher’s elbow)
 medial (golfer’s elbow)

Ganglion cysts (“bible bumps”)
Harris RSI -- LISA '99
33
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.)
Harris RSI -- LISA '99
34
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
Harris RSI -- LISA '99
35
Radial and ulnar
tunnel syndromes


Radial Tunnel Syndrome
Ulnar Nerve Disorders
 Sulcus
Ulnaris Syndrome
 Cubital Tunnel Syndrome
 Guyon’s Canal Syndrome
Harris RSI -- LISA '99
36
Nerve & circulatory
disorders


Thoracic Outlet Syndrome
Raynaud’s Phenomenon
Harris RSI -- LISA '99
37
Other associated
disorders





Reflex Sympathetic Dysfunction or
Dystrophy (RSD)
Focal Dystonia (writer’s cramp)
Osteoarthritis
Fibromyalgia
Dupuytren’s Contracture
Harris RSI -- LISA '99
38
I take control




Get rid of the braces
Insist on a better diagnosis
Abort the path towards surgery
Start aggressive physical therapy
and bodywork
Harris RSI -- LISA '99
39
The traditional
medical team



General, family or adult practitioner
Physical therapist(s)
Specialists:
 Orthopedist
 Hand
surgeon
 Neurologist
 Occupational/sports medicine
doctor
 Physiatrist
 Rheumatologist

Harris RSI -- LISA '99
Pain management
specialist
40
The alternative
medical team

Massage therapist(s)
 neuromuscular
therapy
 Swedish or shiatsu
 Rolfing or Hellerwork
 Feldenkrais




Osteopath or chiropractor
Acupuncturist
Naturopath
Yoga instructor
Harris RSI -- LISA '99
41
Medication

Non-steroidal anti-inflammatories
(NSAIDs)
 ibuprofen
or fenoprofen
 Butazolidin, Indocin, Voltaren

Pain medication
 OTC:
aspirin, acetaminophen
 Painkillers: codeine, Perkocet,
hydrocodone

Cortisone
Harris RSI -- LISA '99
42
Splinting




Splints are controversial
Often indicated for CTS or
DeQuervain’s syndrome
NEVER use them while typing!!!
“Braces” aren’t much better
Harris RSI -- LISA '99
43
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…)
Harris RSI -- LISA '99
44
Physical Therapy







Deep-tissue massage
Phonophoresis
Iontophoresis
Ultrasound
Transcutaneous electrical nerve
stimulation (TENS)
Upper body exerciser (UBE)
machine
Neuromuscular stretches
Harris RSI -- LISA '99
45
Occupational
Therapy



Work hardening is a no-no for RSI
Posture retraining
Preventative exercise
 Stretching
 Strengthening
Harris RSI -- LISA '99
46
Alternative
therapies





Acupuncture
Spinal manipulation
Massage therapy
Vitamins
Yoga
Harris RSI -- LISA '99
47
What not to do

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



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
Harris RSI -- LISA '99
48
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
Harris RSI
-- LISA
'99
49
(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
Harris RSI -- LISA '99
50
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”
Harris RSI -- LISA '99
feeling
51
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
Harris RSI -- LISA '99
52
Patience!



RSI takes a long time to heal
Endurance is the last thing to
return
Keep a log
Harris RSI -- LISA '99
53
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
Harris RSI -- LISA '99
54
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!
Harris RSI -- LISA '99
55
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
Harris RSI -- LISA '99
56
Dealing with flareups




Ice
Heat
Frequent breaks
Stretches
Harris RSI -- LISA '99
57
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”
Harris RSI -- LISA '99
Even the
best positioning needs to58
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
Harris RSI -- LISA '99
59
The keyboard

Fancy keyboards aren’t always the
best
Harris RSI -- LISA '99
60
Ergonomic
keyboards

Comfort Keyboard
 too
adjustable?
Harris RSI -- LISA '99
61
Ergonomic
keyboards

Microsoft Natural
Not adjustable
 Requires radial
deviation
 Forward tilt is
good

Harris RSI -- LISA '99
62
Ergonomic
keyboards

IBM Options
separate pieces
allow for infinite
adjustability
 but
discontinued...

Harris RSI -- LISA '99
63
The mouse


An ergonomic nightmare
Options to think about
 Cordless
mouse
 New Microsoft Intellimouse

Avoid using the mouse whenever
you can
Harris RSI -- LISA '99
64
Alternate pointing
devices



Trackballs are bad
Graphic tablets are pretty good
Avoid pronation, dorsiflexion and
ulnar deviation
Harris RSI -- LISA '99
65
An example of bad
ergonomics

Logitech Trackman Marble FX
Harris RSI -- LISA '99
66
What about
laptops?



You can use a laptop
ergonomically
Lighter vs.. bigger keyboard
Move around!
Harris RSI -- LISA '99
67
Ergonomic furniture
101



The table
The chair
The keyboard tray
Harris RSI -- LISA '99
68
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?
Harris RSI -- LISA '99
69
The chair




Height
Forward tilt
Lumbar support
Armrests
Harris RSI -- LISA '99
70
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?
Harris RSI -- LISA '99
71
The ideal
ergonomic setup
(IMHO)





Good chair
Flat sit/stand station
Keyboard tray w/mouse pad
Graphics tablet
LCD screen
Harris RSI -- LISA '99
72
Random ergonomic
nostrums




Wrist rests
Forearm rests
Cording keyboards
Weird input
devices
Harris RSI -- LISA '99
73
Web sites for more
info


The Typing Injury FAQ -www.tifaq.org
Deborah Quilter’s www.rsihelp.com
Harris RSI -- LISA '99
74
Slides

http://metalab.unc.edu/~harris/rsi
Harris RSI -- LISA '99
75