Repetitive Strain Injuries Disclaimer: ========== This is an informal and non-expert compilation of things I've observed during years of figuring out how to get over RSI and prevent relapses. The advice is worth what you pay for it - but perhaps it will save you from serious RSI. And of course, ask your doctor. At least this will give you something to ask your doctor about. Contributors to the Problem: =========================== The nerve/muscle/tendon etc. systems involved in typing run from your fingertips to your back. Any injury along the way can contribute to numbness, pain, loss of strength in any other part (damage in one area may be felt as pain that is "referred" to another area). Office equipment - chairs, desks, etc. - are designed for people around 5'10" or so. Keyboards are only designed for one size hand (not mine); and, the layout is not the most ergonomic, and there's no shock absorption on most computer keyboards (the impacts of hard plastic keys against a hard surface, transmitted to the only non-rigid object around - your hand 1000s of time per day - think about it). Prevention: ========== * Adjust every inanimate object! Desk height, monitor angle, chair height/back angle, font size, screen colors, extraneous lighting, (your boss, your advisor, your officemate...)... so that you are well supported and not physically stressed. E.g., eye-strain might lead to neck tension which compresses muscles around the nerves and leads to all kinds of fun hand/arm problems. * Take breaks (every 20 minutes or even every 10! ). Walk around, stretch (a simple extended yawn/stretch like the kind you do when you're just waking up); lie down to give your back a break. * Yes, sleep - this saves your back (your spine gets compressed during the day), which after all, has something to do with how happy your hands are. In addition, the hours you sleep are hours in which you won't be typing. * Good posture when typing - feet flat on floor, shoulders back and supported by resting on the rest of your body (not by your neck muscles) back straight. No slouching! * Stretch. Do some stretching every TEN minutes. The simplest to do is just an extended yawn, stretching whatever needs stretching in the process (pretend you're doing modern dance...) There are some great stretching exercises in Pascarelli & Quilter. * Push-ups - well, they help me. It's something to try if it doesn't aggravate anything. Loosens shoulders (when you're done), improves circulation, ... * Exercises that strengthen your back - (sit-ups?). Helps maintain good posture - common sense, right? * Keep your wrist-hand-forearm level when you type, as if you were playing piano. Note: Wrist bent back is really bad - compresses nerves and/or pushes them against the various tunnels they run through, irritating the nerves. * Don't twist wrist from side to side when typing - move the whole forearm instead. The side to side motion is an effective irritant for anything that passes through the wrist. * Type lightly!! If you can, type heavily enough so something shows up on screen, and lightly enough so the key doesn't hit the base of the keyboard when you press it. Advised because. RSI is the cumulative effect of, among other things, repetitive tiny impacts of fingers on hard surfaces (key surface) slamming into other hard surfaces with no damping or shock absorption. * Avoid holding down more than one key at a time with one hand: e.g., use CAPS LOCK instead of SHIFT-whatever, or press SHIFT with the right hand, and the other key with the left (same for CTRL, META, ESC...). i often just type lowercase to avoid using the shift key. * Consider using vi instead of emacs - far less double-keying. * Reconfigure your keyboard, if needed, to avoid double-keying and to maximize the use of thumbs (strongest) vs. pinkies (weakest). I.e., map frequently-used double-key commands and sequences to a function key. * Thumbs should rest on something, not be held up in the air. If your hands are large enough, rest thumbs behind the space bar; if not, you could do what i did - cut off about 1 inch at each end of the space bar, replacing them with rubber pads and rest your thumbs on those. * Especially, try to keep thumbs and pinkies (is there a more age-appropriate term for that finger?) RELAXED. A relaxed hand will followed, and a relaxed typing hand is a happy hand. * If your hands go numb or hands and arms feel irritated, run them under hot or cold water, or both in sequence, for a few minutes. Whether you use hot or cold depends on the symptoms. Or trial and error. Heat relaxes the muscles, reducing compression of nerves; on the other hand, cold reduces inflammation and swelling, e.g., of tendons that could be pressing on the nerve. (Ask your doctor whether you should do hot, cold or both!!) Prosthetics for you or your office (no i don't get commissions): --------------------------------------------------------------- * Hand-Eze gloves (keeps hands warm, and supposedly massages your hand, increasing circulation). Available at the MCC (MIT) for ~$15. Also distributed by Dome Publishing company (really!) at 1-800-432-4352. * Splints, to prevent you from moving your hand from side-to-side at the wrist. * Movable wrist supports. These can either attach to your chair, or are the clip-on kind that attach to your desk. (these are about $100/$150 each, although I've seen them in the Global catalog for less!). I've found it helpful, although Pascarelli and Quilter's book (discussed below) advises against them. On the plus side, my phys. therapist looked at the literature for my arm rests (called ErgoArms, made in Finland) and approved. Their big advantage is that they take the strain off your shoulders - tense shoulders and neck are bad! Second advantage - they allow you to position your hands on the keyboard without twisting your wrist. Disadvantage - they must attach to a VERY stable surface - most keyboard trays do not have this attribute. * Foot rests if the floor is too far away from the lowest chair position. Alternatively, you can try replacing the wheels with smaller wheels or non-rolling surfaces. * Ergonomic chairs. Especially, chairs that don't force your shoulders forward - only a problem for those whose shoulders are narrower than the chair back. You may have to replace the back of the chair with a narrower one, or even a homemade equivalent (plywood, foam rubber & fabric should do it!). * Have your table at right height. Better yet, get an adjustable table or a keyboard tray. A table lower or higher than standard is fine if it fits you, but the advantage of adjustable surfaces are that your needs may vary from day to day. Caveat: most keyboard trays are only long enough to accommodate a keyboard, but not a mouse. What I did was to buy a piece of scrap Plexiglas, about 9" x 27", for $2, and clip it with one of those giant binder clips to the tray. it won't hold up in an earth- quake, but otherwise is quite serviceable. Where to buy? I've forgotten but it's in Somerville, under Plastic in the Yellow Pages, probably and I believe it was on the McGrath Highway. * Mouse or track ball (or neither!)? There are advantages and disadvantages to both! The advantage of a track ball is that your hand doesn't move much, and you are doing fine positioning of the cursor with smaller muscles; with a mouse you're doing fine calibrations with large muscles not designed for that (shoulder, arm..). The disadvantage of a track ball is that it can be hard to get one that doesn't force your hand into a funny position; also, I've found that the keys on the track ball holder can be irritatingly hard to push. On the other hand (so to speak) many people report that mice-like inputs (vs. keyboard) really irritate them and aggravate their RSI. So you can also try: * mousing with your non-dominant hand * mapping frequent mouse operations onto keystrokes instead. QuickKeys on the MAC is great for this!! Follow links in the RSI section for various alternate mappings. But back to the matter at hand, when investigating point-and-click devices, consider the following: * If you get a track ball, notice that the balls come in different sizes. Get one with a ball that is the right size for your hand. * If you get a mouse, avoid one with a ball-bearing type mechanism - the ball rolls on the pad and eventually gathers dust and debris - then you're fighting friction. Mice that slide rather than roll - e.g., optical/laser mice or the kind that come with DECstations - will provide much less resistance. Also, consider getting: * the lightest mouse you can find, * the one that moves with the least friction * one whose keys are easy to press, * a 1-button mouse rather one with >1 buttons -- why? because there's less strain re: aiming when you only have one button. You can click the right button with your hand in any number of positions - with >1 button, your hand position is more restricted. You *should* be able to approximate the other functions with some combination of a mouse click + a key (which of course, you type with your non-mousing hand). * or a >1 button mouse which has a click-hold option so that with a simple click you can lock in the mouse for dragging without having to keep your finger on the key until you're done with the mouse operation. * Or, none of the above - try a glide-point (pen or finger-based tablet). * Look into alternate input devices - one-handed kbds, split keyboards, DataHand. Split keyboards are a good alternative, because they allow each arm to point straight ahead, minimizing compression at the shoulder. A split keyboard should really split into two completely separate pieces, for most flexibility. The DataHand was too large for me (they might now make it in varying sizes), cost ~$1000 (this may have changed) and did not work for the Unix boxes (this may have changed too). The price was prohibitive for me, but I did try one - its advantages are: the impact of finger against key surface is minimal; you don't move your hand, just your fingers; you hardly move your fingers at all; the 2 input devices are completely separable; they are also configurable. The number (last I checked): 602-860-8584 (Scottsdale, AZ). They might now have an 800 number. * Other alternative input devices - foot pedals for control-type keys -- SHIFT, ESC, META, CTRL, etc. * Raising the front part of the kbd helped me, by creating a more level plane in which to move my hands and fingers. Your mileage may vary... * Speech recognition devices. Speech recognition is getting much better and is much more commonly available than when I first wrote this page. Sorry I don't have much more information on this, but do pursue it. (And let me know if there's something I can add to this section..) Common sense about office furniture: =================================== * One size does not fit all!!!!! This goes for shoes, clothing, and coincidentally, chair size, desk height, keyboard tray length, keyboard size, mouse size. When looking for office equipment, remember: * Look for independence of function. For example, a keyboard tray that changes its angle according to its height is less desirable than one in which height and tray angle can be adjusted separately. And a chair whose arm rest angle is dependent on the seat angle is also less desirable than one in which the angles are independent. * Continuous is better than discrete. E.g., a tray table that has fixed (discrete) settings << one whose with no fixed settings, and therefore theoretically infinitely adjustable (ok i'm a nerd). * Shoddy construction sucks. Look for connections, fittings, materials, that will wear well with continued use.. E.g., metal >> plastic >> particle board. Make sure it (chair, work surface, monitor stand..) doesn't wobble and is stable in whatever position you set it in. Symptoms of RSI: =============== Numbness, pain anywhere along hands/arms/shoulders/back. Hands/arms weak. Trouble grasping - dropping things... certain arm/wrist/hand motions are painful, waking up with numb hands and/or arms, no strength, feeling that your limbs or fingers are thicker than usual and slower (etc.) A normally functioning hand/arm should not be numb, painful or weak. In addition, if you do strain the hand/arm subsystem, it should not take (for example) a month to recover from one marathon typing session. Once you've got it: ================== The first step is to skip right over that denial stage and admit you've got it. Even if you've never been disabled before, you are now. Some part of your hands or arms are extremely sensitive to certain positions, impact etc. If you must: * Give up bicycling (pressure on palms, impact from potholes) or adjust/change the handlebar height and angle so you are not resting on your hands; or pad the handlebars profusely! * Open doors with your feet or with fingertips (and hand and arm straight) instead of palms. * Avoid any activity in which you bend your hands back at the wrists! (hence the previous injunction) * Pad everything. Well, I confess, I never got this far, but considered wearing heavily padded bike gloves all the time, and gluing some kind of rubber (Dr. Scholl's callus pads work!) to the keys on the keyboard to reduce the pain on impact. * Sleep on your back (knees raised slightly) and or on your side, rather than on your stomach (twists your neck) * Be careful lifting anything heavy and/or with weight training specifically. You may cause your arm and shoulders to tighten if you don't do it right. Also, in your weakened condition, you may strengthen the wrong muscles in an attempt to compensate for others that are too weak and/or in an attempt to avoid certain painful positions. * Don't be surprised if *handwriting* is painful or difficult as well. To make it easier, grip the pen loosely, try a thicker pen, pad it around the gripping area, and try a heavier pen so you don't have to exert yourself to get sufficient pressure (let the weight of the pen do the work). * Avoid shaking hands - wear a splint or something to signify that you are injured - and if people don't get the hint then just tell them you can't shake hands (I don't know if they make spiked splints). * STOP TYPING!!! Relief, Cure ============ Good doctors (MIT, Boston area): ------------------------------- Dr. David Diamond at MIT Medical. Knows a lot about the interaction of ergonomics and body parts; and about the injuries bad ergonomics can cause. He's always interested in new information, ergonomic software, etc. Dr. Robert McCunney is also at MIT medical. The patient advocate (Janice McDonough) gave me his name as someone else to see for RSI problems. Dr. Fred Hochberg is a neurologist and an expert on hand injuries, esp. for musicians. Practices as MGH and also has a private practice in Brookline. If your problem is not tendinitis (he's a neurologist, remember..?) then he's your man. He correctly diagnosed the specific weakness that was responsible for all my symptoms and referred me to a physical therapist who showed me some useful exercises. I've since heard from other people that I've referred that he was able to help them too. Last contact info I have for Dr. Hochberg: number at MGH 726-2656 Tests: ----- Nerve conductivity tests can determine how damaged your nerves are. Unless pain is your thing, you won't enjoy this test, but... should be done for both arms, according to the doctor I saw at the Occupational Health Clinic at Cambridge City Hospital. Strength tests -- the doctor asks you to resist pressure, or try to pull their fingers apart. I'm not sure how they can get quantitative data from this, but one doctor (gone now) assured me I was stronger (he was right) after the third visit. Misc. how-does-it-feel tests? E.g., if you raise your arms, do they go numb? Neurologists seem to be able to get a lot of data from these tests. Movement tests -- doctors should observe what happens when you perform simple motions, e.g., rotating your arm at the shoulder joint. They should observe from front and back (e.g., shoulder blades should remain stable throughout this exercise). If there's something wrong, then you may be compensating for it by returning to a position in which your nerves are compressed, or your tendons irritated. Drugs?: ------ Ibuprofen reduces inflammation. At the doses you might need though, (600mg, if I remember correctly), you are at eventual risk for kidney damage. Reduced inflammation is good; masking the pain might be a bad thing if you continue to do damage without feeling it. One doctor I saw suggested cortisone injections to reduce inflammation, but only as a last resort. Apparently, cortisone used to be more heavily prescribed for these kinds of symptoms than at present. Prosthetics: ----------- See in Prevention section. Also... hand/wrist braces worn while typing and sometimes, while sleeping depending on the diagnosis of course (am I repeating myself?). Surgery: ------- Sometimes doctors will suggest this for carpal tunnel syndrome. I believe that they scrape out whatever lines the tunnel (cartilage?) to make it wider, and reduce pressure on the nerve that passes through. Misc. Other things that worked (for me and others): -------------------------------------------------- * Acupuncture. * Taking a complete break from typing and fine hand motions!!! I was lucky to be able to take 5 weeks. 3 months would be even better. Do it! Take out a loan if you have to. 3 months is better than (e.g.,) 2 years of relapses. * Rolfing - like heavy duty massage, but heavier duty. Realigns muscles and separates fascia (the muscle covering i think). I tried it on the recommendation of a violinist for whom it worked. It brought back a lot of functionality, ease of movement, etc., and gave me immediate relief from pain. Of course, even after the compression on the nerves is alleviated, they still need to recover, so taking a break from RSI-inducing activities is recommended to get the full benefit. I highly recommend it at least for anyone with my symptoms. Check with your doctor though. Caveat: choose a sensitive practitioner who is willing to be careful around the arms and neck and also willing to depart a bit from the standard 10-session program. They should be a certified Rolfer, that is, certified by the Rolfing Institute. Cost: ~$100 for a ~75 minute session. Rolfer in Cambridge: Aline Newton 661-6409 The Rolfing Institute is in Boulder, CO. They can direct you to certified Rolfers in your area. And here's another caveat - some of the Rolfers I spoke to tend to get involved in psychological/spiritual aspects of physical damage. I suppose they get bored. However, in my extremely humble opinion, I would suggest staying with someone who will work on the physical problems and leave your brain and spirit alone at least until your acute physical symptoms abate. There *is* an advantage to learning new ways of movement, but if you're still in pain or disabled, you won't have much to work with. * And re: new ways to move, sit, stand, type... you might want to check out teachers of the Alexander technique and/or Feldenkreis technique. (I haven't, but some people I know have been helped by this.) * Temporary relief (depending on the problem): hot baths with Epsom salt (soothes sore muscles ; massage - arms, wrists, shoulders, neck; shaking out your arms and hands; warm mud on hands and arms (i never tried this one - it sounds like fun though!) * Type with the index finger only, or with two hands, each holding a pencil, and with the eraser end on the keyboard (to reduce impact). * Win the MacArthur Prize and hire typists (well, it worked for Stallman). * And at the risk of repetitive information syndrome, speech recognition devices and re-mapping your keyboard, especially so that you can execute commonly used sequences with one keystroke. Long term prevention and relief: ------------------------------- * Tai Chi. * Strengthen back and stomach muscles. * Aerobic exercise. Resources: --------- The RSI Handbook, by Pascarelli & Quilter I've heard good things about this book. I've skimmed it but haven't bought it. (I'll buy it one of these days - right now I'm still trying to finish "Creative Procrastination".)