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Repetitive Strain Injury (RSI) is a potentially debilitating condition resulting from overusing the hands to perform a repetitive task, such as typing, writing, or clicking a mouse. 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 anyone who uses a computer about RSI, and to provide useful suggestions for prevention and treatment. The webpage also contains some specific advice for the Rice community, and refers to a number of services available through our university that may be useful in the prevention or treatment of RSI.
This web page was written and is maintained by Clay Scott. You may feel free to contact me if you have questions you think I might be able to answer. I have been dealing with RSI since 1997, so you will find a sympathetic ear with me.
| 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. |
| Warning: You will be tempted to ignore the advice on this page because you don't feel (or acknowledge) any symptoms at the moment. Resist this tempatation! |
Last modified May 21, 2008.
| 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 members of the Rice community, the University is usually willing to make accommodations, but for students, 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 accomidating.
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.
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 the most important ingredient in determining 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.
Unfortunately, it is virtually impossible to find a chair that fits you perfectly, even if you find a chair that is fully adjustable in every conceivable way. In my case, I find it extremely beneficial to use a towel roll wedged behind my back at the base of my spine. This helps keep my pelvis in the proper position, which is the key to good posture.
Highly adjustable chairs can be expensive, costing several hundred, if not one to two thousand dollars. I got my chair at a discount (and it was still expensive!) through the ergonomic supplier for a company I interned at. Check with your employer, or the Rice 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. 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, and (2) read Sitting at Your Computer. My chair belongs to the Superior Performa line. I am moderately satisfied with it (it is the best chair I've found yet), but it doesn't quite go as high as I'd like it to (I am 6' 2'').
If you can't afford a new chair, and if your employer will not provide one, you will have to do the best you can with what you have. The towel roll can be very helpful in this situation.
The next section is related to proper posture.
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, consider finding a separate keyboard (and perhaps a separate monitor) to attach to the laptop, so that you can arrange your workstation properly.
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). Some ergonomic keyboards also allow you to to switch between QWERTY and Dvorak at the touch of a button. 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.
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.
Standard mouse
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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 half 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 dorm frame, as shown. Lunge forward, keeping chest and pelvis facing squarely forward. Hold 30-60 seconds. Try holding upper arm 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. 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.
The Rice Recreation center offers yoga and Pilates classes for $4 or $5 per class as part of their Group Fitness Program. The Rice Yoga Club also offers a free session on Sundays at 4:00 PM (contact shri at rice dot edu).
These articles offer more advice on posture, balance, etc.
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 with whom you need to communicate. Drop out of your fantasy baseball league. Rely on newspapers and books for information, and stop surfing the Web. Instead of playing solitaire on the computer, by yourself a real deck of cards, and play it the old-fashioned way. In general, eliminate unnecessary computer use from your life. And believe me, a whole lot of it is unnecessary.
For typing that you just can't avoid, consider using voice activated software, or arrange to have someone type for you. At Rice, 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. Members of the Rice/Houston community may contact me directly for specific recommendations.
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.
In terms of short term relief, there are a couple of 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, 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.
The other 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 (you'll probably need to put ice in). 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.
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 (NatSpeak), 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 as fast using NaturallySpeaking as I could typing with perfectly healthy hands.
Dragon's other product, DragonDictate, isn't as helpful to me. It requires you to speak one word at a time, which makes it hard to keep your concentration, and can also cause injury to the vocal cords. It's only advantage is that it gives you complete control over every aspect of the computer with your voice. With NaturallySpeaking, you cannot use your voice to start new programs, or to control most applications other than the speech software itself (although newer version of NatSpeak are including some of this functionality).
For Web browsing, I used to use a program called Conversa Web, which is specifically designed for voice operated Web navigation. You can simply read off any link that you want to click. Note that NatSpeak is incorporating web browsing into recent releases.
You may find more information on these products at the following Web sites:
Retailers such as CompUSA or Best Buy may have better deals than these websites. If you have to buy the software yourself, look for a copy of the next-to-most-recent release; it should serve your purposes at a lower cost.
Some final words of advice: voice activated software is not for everyone, so try to use someone else's program before you purchase your own. Also, try to get someone (e.g., your department, your advisor) to buy it for you. Those who do not have an American accent may want to take extra care, since these programs may be designed around an American accent. 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 feelings. Members of the Rice community may take advantage of the (free) Rice Counseling Center.
The Disabled Student Services (DSS) office at Rice University can make your life easier if you have an RSI. DSS can arrange for you to have extensions on assignments that are to be written or typed, and they can also arrange for you to have the services of a scribe to assist you at writing or typing. Other accommodations may also be available.
Please note that 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. You should contact DSS at adarice@rice.edu or campus extension 5841 for more information.
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.
Another fantastic 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. I think I'd recommend this one before the Pascarelli book, although both are great and either one would be worth your time. The authors also maintain a website devoted to the RSI cause (see below).
I have copies of these books that you may borrow. If you have any problems, you should definitely read one of these books, and if your problems are serious, you should definitely buy one or both.
Please direct comments and questions to Clay Scott
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