Repetitive Strain Injury (RSI) is a potentially debilitating condition resulting from overusing the hands to perform a repetitive task, such as typing, clicking a mouse, or writing. Anyone who uses a computer regularly is at risk and should know about RSI. Unfortunately, most people are uninformed and do not understand what RSI is or how serious it can be. This webpage is intended to educate computer users about RSI, and to provide useful suggestions for prevention and treatment. Much of the information provided here is also relevant for RSIs derived from other activities such as playing an instrument, gaming, or any other repetitive task. The page additionally contains a few specific pieces of advice for students.
This webpage was written and is maintained by Clay Scott. I have formatted the site as a single page in order to minimize clicking, and so that you can easily print the page if you prefer. You may feel free to contact me if you have questions that I might be able to answer (email preferred)). I have been living with RSI since 1997.
|Disclaimer: I am not a medical doctor, and have no medical training. While every attempt is made to keep this page up-to-date with the best medical advice I have received, it is not a substitute for obtaining professional medical advice, diagnosis, or treatment.|
Last modified Feb. 13, 2015.
|What is RSI?||If you develop RSI
(Adapted from Repetitive Strain Injury by Dr. Emil Pascarelli and Deborah Quilter)
In simple medical terms, repetitive strain injury (RSI) is defined as a cumulative trauma disorder (CTD) stemming from prolonged repetitive, forceful, or awkward hand movements. The result is damage to muscles, tendons, and nerves of the neck, shoulder, forearm, and hand, which can cause pain, weakness, numbness, or impairment of motor control.
You may wonder how seemingly innocuous activities such as typing and clicking a mouse button could possibly be harmful. Fine hand movements, repeated hour after hour, day after day, thousands upon thousands of times, eventually strain the muscles and tendons of the forearms, wrists, and fingers, causing microscopic tears. Injured muscles tend to contract, decreasing the range of motion necessary for stress free work. The sheaths that cover delicate tendons run out of lubrication because they aren't given time to rest, so tendon and sheath chafe, resulting in pain. Due to this abrasion, tendons become inflamed, and begin to pinch neighboring nerves. This can result in numbness, tingling, or hypersensitivity to touch. Unless this cycle is interrupted, it repeats itself over and over, and a long-term, chronic problem results.
Repetitive strain injury can affect more than just your hands and wrists. Poor posture can lead to severe neck and back injuries. Staring at a computer screen can lead to eye strain. Repetitive reaching for a mouse can lead to arm and neck strain as well as spinal asymmetry.
RSI is not a specific medical diagnosis, but rather a family of disorders. Many people mistakenly equate RSI with carpal tunnel syndrome, even though CTS is only one particular form of RSI. One recent study even reported that frequent computer users are no more likely to develop CTS than non-computer users. Don't let this mislead you, though. Many other forms of RSI do come on as a result of frequent computer use.
The three primary risk factors are poor posture, poor technique, and overuse. These topics are discussed in depth in the section on prevention. In addition to these, there are several other risk factors to be aware of. While they may not cause RSI on their own, they can increase your risk if you already possess one of the three primary risk factors. The following list (adapted from Pascarelli and Quilter) lists several risk factors. You may be at risk for developing an RSI if you:
Consult Pascarelli and Quilter for further information.
The primary warning sign of RSI is pain in the upper extremities (fingers, palms, wrists, forearms, shoulders). The pain may be burning, aching, or shooting. It could be local (e.g., fingertips) or diffuse (e.g., the entire forearm). The pain will typically be increased after a long session of computer use. Keep in mind, however, you can have severe RSI without experiencing pain. The following checklist (adapted from Pascarelli and Quilter), can help you determine whether you have RSI:
Do you experience:
In addition to these symptoms, RSI can also lead to behavioral changes. You may not even be aware of these changes. For example, do you:
If you develop RSI, and do not take steps to correct the problem, there may be serious repercussions. When my RSI was at its worst, I was unable to open doors, prepare my own food, do laundry, drive, write, type, and shake hands. This lasted for half a year. I was unable to type regularly for about three years. Many RSI sufferers complain of similar problems. In addition to limiting your day-to-day functionality, this decreased independence can cause a significant emotional burden.
RSI can limit your ability to perform at work. Recent Supreme Court rulings do not view RSI as a disability, and hence, RSI is not covered under the Americans With Disabilities Act. (Apparently typing is not a "major life activity," according to a recent opinion authored by Sandra Day O'Connor, for those whose job requires significant amounts of typing.) Therefore your employer may fire you if you are unable to perform your job because of your RSI. The prospect of changing (radically, in many cases) your profession is obviously a daunting thought. For students, most universities are willing to make accommodations, but lost productivity due to RSI could still delay your graduation one or two years. And once you graduate, your next employer may not be as accommodating.
As with all health-related issues, it is wise to eat well, exercise, listen to your body, and avoid destructive behavior. However, there are some specific precautions you can take to help prevent the onset of RSI.
When you first notice symptoms of RSI, you have already done substantial damage to yourself. RSI can take months, even years to develop, and you can expect it to take at least twice as long to heal. It has been several years since my RSI was at its worst, and even now I must limit my typing. Even if you feel no pain or other symptoms of RSI, you would do well to heed the following advice for RSI prevention, especially if you meet one of the risk factors outlined above.
What is good posture? For our purposes here, good posture is when you are seated in such a way that the effort required to work at your computer is minimized. The following checklist identifies the proper way to sit in order to achieve good posture:
There can be exceptions. For example, it's OK to shift your legs and feet around if they get figgety, but be sure to always keep the spine neutral and the head balanced above the pelvis.
Unfortunately, the above written description can be very difficult for some people to actualize. Over the course of our lives, our bodies become so habituated to certain patterns of muscle tension, that we are unable to accurately perceive ourselves. For example, I may feel like my spine is in a neutral position, when in fact my lower back has too much arch. Even if I were to show you pictures, that would not solve the problem because (1) the difference between good and poor posture can be subtle, and (2) even if I could perfectly describe proper posture to you, your brain may not have the ability to accurately put your body in that position, because of the aforementioned habitual patterns. One solution to this dilemma is to have a skilled teacher re-educate you on postural awareness. This can be done by someone trained in a form of "bodywork" such as the Alexander technique. Another strategy is to regularly practice gentle yoga or other practices that enhance mind-body awareness.
I believe that your posture at your workstation is the most important factor in determining your risk for RSI. Moreover, in my experience, your chair is a major determinant of your posture. I cannot overstate this. Sitting at a workstation entails holding your body in a static position (described above) for long periods of time. Holding yourself in this position puts strain on your muscles. The less support you receive from your chair, the more strain is placed on your body. Therefore, it is essential to have a chair that supports you as well as possible.
The key to a good chair is adjustability. A good chair will be adjustable in the following ways:
It is also important to have a firm seat, so that your pelvis can be firmly grounded, but not too firm, so that your rear isn't killing you after a short time. Be careful to avoid chairs with a bucket seat, i.e., a seat that makes your pelvis rock back. Tall people will prefer a chair with a high backrest. A head/neck rest should not be necessary, since your head should be balanced over your spine. Wheels are also nice, if you have a carpeted floor, although wheels on a wooden floor may slide around too much. The seat pan should be long enough such that the space between your calves and the end of the seat pan is about two finger-widths. If you are tall, you may need a chair with an extra long seat pan. For my back, I sometimes use a support called TruComfort, which I have found to be very helpful.
Highly adjustable chairs can be expensive, costing several hundred dollars. I got my chair at a discount (~$700) through the Ergonomics Office at my university. Check with your employer's ergonomics office, to see if you can receive a similar discount. If you can afford it, a good chair is definitely worth the investment, and the higher the quality, the longer it will last you. A well made chair should last 20 years or more. But be careful when purchasing a new chair: many models say they are ergonically designed, but are not. Be wary of less expensive models sold at box stores; you will get what you pay for. I recommend that before you buy a chair, you do two things: (1) Use the chair for a week to make sure it fits you (your ergonomics office may have a loaner program.), and (2) read Sitting at Your Computer.
Another option is a standing desk. You'll want to be able to move back and forth between standing and sitting, so you need a height-adjustable desk (preferably electric powered), or a contraption that sits on you desk and can raise up, like this one.
If your company has an ergonomics office, they likely employ an occupational therapist who can come to your office and help you set up your workstation.
There are three pieces of equipment that require special attention:
This last point is very important, but can be problematic if you only have one desk, and like space to write. In this case, I suggest one of three possibilities: (i) Find another place to write, such as the library; (ii) Get a cheap computer desk if you have room in your office; (iii) Find a rolling or sliding tray to put your monitor on, so you can move it aside when you need to write. If you don't position your monitor correctly, it can lead to severe neck strain over time. For example, if your monitor is too far back on your desk (or if your font is too small), you will have the tendency to hunch forward and jut your head out, in a subconcious effort to see the screen better. This leads to another key point: Don't use really small fonts! It leads to poor posture and eye strain.
If you use a laptop, you will find it is vitually impossible to use good posture. This is why I strongly recommend against the use of a laptop as an everyday computer. I used a laptop all through college, and I know it contributed to my RSI. If you do most of your work on a laptop, you really need to find a separate keyboard so that you can put your laptop on a box or some books, and have your monitor at eye level. You could alternatively find a separate monitor, but laptop keyboards tend to be too small. Another novel solution is the lightweight and highly portable Roost Stand.
There are three keys to proper typing technique.
An ergonomic posture reminder that you can post near your computer was created by Clemens Conrad.
There is another keyboard layout, in addition to the standard QWERTY layout. Called the Dvorak layout, it was designed to minimize the movement of your fingers as you type. In contrast, QWERTY was designed to maximize the amount of finger movement, so as to avoid jammed levers in old mechanical typewriters. Most operating systems allow you to switch your keyboard to this format (in Windows, try Control panel -> Regional and Language Settings -> Languages -> Details). When I switched to the Dvorak layout, there was about a month of transition time where I wasn't able to type as fast as I used to. Now, I have less pain in my hands than before I made the switch. You can find Dvorak typing tutors online.
In addition to Dvorak, there is yet another layout called Colemak that is designed to improve upon Dvorak. For example, Dvorak has the "s" and "l" letters typed by the right pinky which puts execive strain on this digit. It is not currently standard in operating systems like Dvorak is, but you can download the software from the link above.
Using a mouse can be even more harmful than typing. Here are three reasons why this is so:
My solution for these problems has been to switch to a trackball. This has the advantage that the mouse is stationary: you don't have to move your whole arm to move the pointer across the screen, which reduces strain on the arm, shoulder, back, and neck. It also has extra buttons, which can be programmed to double-click or drag with a single click. Moreover, the work is more evenly distributed among the fingers. Actually, I have two mouses. One is a trackball on the left, and the other is a standard mouse on the right that I use for scrolling and moving but never clicking.
Another solution is to use key commands to operate in a windows environment, rather than the mouse. Once you learn the commands, this method is often faster than mousing. A solution that will not work is switching which hand you use to click the mouse. This may provide temporary relief, but soon your other hand will be as bad as the first.
In addition to typing and mousing, writing can add significant strain to your hands. It is important to hold your writing utensil lightly. Someone should be able to pull it out of your hand when you are writing. It also helps to use a writing utensil that doesn't require you to push down too hard. Ball point pens should be avoided. I recommend soft lead pencils, or the Dr. Grip Gel Ink pen.
In this section I offer some specific recommendations for stretching and strengthening exercises that have helped me. These fall under the category of prevention as well as recovery. Most of them you can easily do in your office during breaks, which you should take every hour or so.
Wall stretch: This is my favorite stretch. It is great for stretching out the shoulder, arm, wrist, and hand all at once. Extend the arm along a wall, with arm parallel to the ground and palm facing wall. Attempt to open chest so that shoulders are perpendicular to arm. Extend fingers and palm away from wall as much as possible. Your hand may tingle - this is OK. Hold for 30-60 seconds. Try with the arm at different angles. Repeat on other side.
Doorway: This stretches the pecs and shoulder. Hold elbow at a right angle, and place forearm along door frame, as shown. Lunge forward, keeping chest and pelvis facing squarely forward. Hold 30-60 seconds. Try holding arms at different angles. Repeat on other side.
Back and neck strengthening: The other thing I do that really helps is an exercise that involves one of those big exercise balls, a long dowel rod, and a couple of 3 (or 2) pound dumbbells. You get on your knees, lay your chest on the ball, put the rod on your back so that it makes contact with your rear, back, and head (to keep the spine neutral). The ball should be big enough so that the rod is sloping slightly up. Then just slowly raise the dumbbells off the ground and lower back down. You can have the arms at different angles, but start with them extending behind you, as that is easier. Also try turning your head from side to side occasionally as you go, to activate the neck muscles. You do not need heavy weights for this exercise to be effective, and heavy weights may in fact strain your already fatigued muscles.
Correct breathing: It's amazing how stress and computer use can corrupt our natural way of breathing. I highly recommend Barbara Conable's short little book on breathing called The Structures and Movement of Breathing: A Primer for Choirs and Choruses . Don't worry that it is written for choirs, there's a lot of useful info for everyone.
Eye palming: A relaxation technique for the eyes is to place your fingers crossed over your forehead and cover the eyes with your palms. Do not apply pressure to the eyeball. Just concentrate on the blackness for a while. Another simple but great technique is to just look out the window at a distant scene.
The above exercises are primarly geared toward relieving/preventing the symptoms of RSI. If you want to eliminate the root causes of RSI, you must focus more on stretching, strengthening, and re-educating the core muscles of your body responsible for maintaining proper alignment and posture. It is not possible for me to explain how to do this here. However, there are several practices/techniques that aim at this goal, including yoga, Pilates, the Alexander techique, the Feldenkrais method, and T'ai Chi. You can probably find a group class in the $10-20 range in your area if you live in a large city or near a University. Yoga and Pilates can also be learned from books and videos, but it is usually better to learn from a teacher and to practice with a group. Personally, I have derived benefit from yoga, Pilates, and especially the Alexander techique.
More articles on posture, balance, etc. may be found at Core Awareness.
Be prepared to make some changes in your lifestyle and your computer habits. In particular, make an extra effort to follow the guidelines laid out in the previous section on prevention. Following these guidelines can decrease your recovery time, and help you avoid relapses in the future.
OK, it's not always quite that easy. Very few people have the luxury of being able to avoid typing altogether. However, if you think carefully, you'll find there are many ways to eliminate unnecessary typing from your life. For example, instead of sending e-mail, use the phone, or better yet, get out of your chair, walk down the hall, and speak face-to-face to the person. Drop out of your fantasy baseball league. Rely on newspapers and books for information, and stop surfing the Web so much. Instead of playing solitaire on the computer, buy yourself a real deck of cards, and play it the old-fashioned way. Just check your email twice a day. Et cetera. In general, eliminate unnecessary computer use from your life. And a whole lot of it is unnecessary. It may seem like a sacrifice, but your health is worth it.
One technique I use is the following: when I am at my office, throughout the day I use an index card to record all of the e-mails I wish to send. I keep the index card in my back pocket. Then as soon as I get home from work, I will use my dictation software to compose all of the e-mails in one sitting. This has many advantages: it saves me from the tendency to type quick e-mails with my hands while at work; I am less distracted by e-mail at work; if you don't respond to an e-mail right away, sometimes the need to ever respond goes away; once people learn that you don't respond to e-mails right away, they send you less e-mail.
For typing that you just can't avoid, consider using voice activated software, or arrange to have someone type for you. Grad students, you might ask your deparment coordinator if there are any clerical assistants that you could borrow.
If you believe that you may have developed RSI, the first thing you should do is to implement all of the prevention strategies outlined above. If you find that your situation continues to worsen, you should consider seeking professional medical advice. A general rule of thumb is that if your hands still hurt a couple of days after you last typed, you need to see a doctor.
If you have RSI, finding a good doctor or physical therapist is definitely worth the time and money.
Unfortunately, finding a doctor who is competent to diagnose and treat RSI can be a challenge. Some doctors doubt the existence of RSI, and many others dismiss it as an insignificant problem. Some doctors don't know the first thing about treatment, while others encourage their patients to undergo unnecessary (and possibly dangerous) surgery in hope of a quick fix. With that in mind, know that you must be careful and selective when choosing a physician.
Most general practicioners will be unable to give you specific advice. However, your primary care physician can still be a valuable ally. If he or she can recommend a good physical therapist, and is willing to write you a prescription for PT, that is often the best way to go. The PT can diagnose you and formulate a treatment plan.
If you or your insurance or PCP insist on seeing a specialist, in my experience, the best doctors are physiatrists, sometimes listed under Physical Medicine and Rehabilitation. Check with your health-care provider to find physicians in your area.
In general, your doctor/therapist should prescribe treatment that focuses on the cause of your symptoms, rather than the symptoms themselves. In other words, the treatment should not be focused on pain management, although that may be one aspect. Rather, it should be focused on correcting your posture, and improving your anatomical function, so that, with time, your body will heal itself. Treatment should typically consist of visits to a physical therapist, coupled with a home exercise program. The focus of this program is to stretch overly tight muscles, and strengthen weak ones. Remember however, that no amount of physical therapy and strengthening/stretching can overcome excessive typing, poor posture, a bad workstation, or poor typing technique.
When you first visit with any health care provider, be sure to ask them about their experience in treating RSI. If they do not seem knowledgable, ask for a referal to someone with more experience.
In terms of short term relief, there are some simple things I've found that help me. One is to massage my forearms with a tennis ball. Put the tennis ball on the ground or some non-slick surface (like carpet) and press down on it with your forearm and roll it around. Try a variety of positions and movements, and also be sure to massage the top of your forearm, applying the ball with your other hand.
I also recommend the tennis ball self massage to the muscles in between the spine and shoulder blades. Stand up against the wall and find a tender spot, and hold/breathe into it for 3 cycles. Then move to a new spot and repeat. As you get used to it you can stay longer in those trouble spots. (Thanks to Henriette Bruun for this suggestion).
Another thing is a hot/cold water bath. Fill two sinks or buckets, one with water as hot as you can stand, the other with water as cold as you can stand (use ice). Soak your arms and wrists in each bath for 2-3 minutes at a time, and alternate baths about 3 times each. This is very good for numbness/tingling kinds of discomfort.
Keeping your hands warm while you type is critical. When it's cold, consider wearing a pair of thin liner gloves with the fingertips cut off. Or take occasional breaks to run your hands under warm water.
Finally, the wall and doorway stretches above can provide some degree of relief.
Is surgery ever the right choice? Recall that there are many different types of RSI. For one particular form of RSI, namely carpal tunnel syndrome, a minimally invasive and effective surgical procedure has been established. Look for a hand center in your area to consult with a physician about this option. To determine that you have CTS and not some other RSI, they should perform a nerve conduction study, known as an electromyogram. Also keep in mind that even if you have surgery and it is successful, your symptoms may return if you do not improve your computer habits.
For other forms of RSI, surgery may not be an appropriate treatment. Even if you have CTS, you may wish to consider nonsurgical options (workload reduction, improved ergonomics, physical therapy; see above). Without surgery, recovery is still very much possible. In my case, I did not have CTS, and never considered surgery. At it's worst, the severity of the pain in my hands/wrists was about a 9 out of 10, and I could barely grip even the lightest objects (e.g., I would turn faucets on and off using my elbow). Now, I play tennis and the banjo regularly, and do a minimal amount of typing, relying on dictation software for the rest. I still have occaisonal pain when my workload increases, but it goes away with a couple days rest. It's not a complete recovery, but it's sufficient for my lifestyle.
Here are five general tips that I have found to be helpful. If you don't think you are able to spare the time or money to implement these ideas, think again. You are probably underestimating the value of a healthy body.
There are several voice activated applications intended for document composition. I use Dragon NaturallySpeaking, which can understand non-technical English, spoken at a natural pace, at a very high recognition rate. If I'm writing something non-technical, I can usually compose it faster using NaturallySpeaking as I could typing with perfectly healthy hands. You can also train it to use learn technical terms you use frequently.
Retailers such as Best Buy may have good deals. Look for a copy of the next-to-most-recent release; it should serve your purposes at a lower cost, and place less demand on your computer's cpu and memory.
I have found that the microphones that come with NaturallySpeaking break easily and are highly sensitive to ambient noise. Therefore I recommend purchasing your own headset separately. I use this model made by Logitech. With this microphone, I have no trouble using NaturallySpeaking in my office, where the air vents make it too noisy for the cheaper microphones to work effectively. This extra microphone can also be used for other purposes, such as skype or listening to music.
Some final words of advice: Those who do not have an American accent may want to take extra care, since these programs may be designed around an American accent (I'm not sure). Do not expect to be able to use dictation software to do computer programming; As for composing technical documents, i.e., documents that use specialized jargon or equations, I haven't found any application well-suited to this problem yet. Make sure your computer's processor speed is 20-30% faster than the recommended speed for good perfomance.
An advanced case of RSI can cause a significant emotional burden. Because of your limited use of your hands, you'll constantly be asking other people for help just to get by in life. It can be quite challenging, for example, to ask someone you don't know to give up their seat on the bus for you because your hands are too weak to hold the hand rail. On the other hand, you will find that most people are willing to help you out in your time of need. Take advantage of close friends and mentors who would be willing to listen to your struggles, and help you sort out your thougts and feelings. Universities often have Counseling Centers that are free to students.
Most Universities now have a Disabled Student Services (DSS) office that can make your life easier if you have an RSI. DSS can possibly arrange for you to have extensions on assignments that are to be written or typed, and they can also arrange for a scribe to assist with writing or typing. Other accommodations may also be available.
Please note that typically DSS can not offer you any assistance unless you have written documentation from a licensed physician that details the nature and severity of your problem, the medical treatments currently prescribed, the expected time of recovery, the accommodations you would benefit from during your recovery, and the credentials of the diagnosing physician.
Repetitive Strain Injury: a Computer User's Guide, by Pascarelli and Quilter (John Wiley and Sons, 1994), is a comprehensive source of information on how to prevent, live with, and recover from RSI. Much of the information from this webpage comes from this book, and the book contains far more detail than I was able to include here. Deborah Quilter maintains an RSI website (see below).
Another excellent book is It's Not Carpal Tunnel Syndrome! RSI Theory & Therapy for Computer Professionals by Suparna Damany and Jack Bellis (Simax, 2001). This gives a very down to earth, plain-spoken account of what RSI is, how it should and should not be treated, and plenty of good practical advice on coping, home-remedies, and getting professional help. The authors also maintain a website devoted to the RSI cause (see below).
Please direct comments and questions to Clay Scott
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