Preventing RSI

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.

Why bother?

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.

Good posture is crucial

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:

• Feet: flat on the floor
• Knees: directly over feet, bent at right anlges (or slightly greater), with a couple inches of space from the chair
• Pelvis: rocked forward, sitting on the "sitz bones," with hips (the sockets where your femurs attach) positioned no lower than, and perhaps slightly higher than the knees.
• Lower back: arched in, and possibly supported by your chair or a towel roll.
• Upper back: naturally rounded
• Shoulders, arms: relaxed, at side.
• Neck: arched in, relaxed, supported by spine. Be careful not to hold tension in back or under chin.
• Head: balancing gently on top of spine.

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:

• Height of seat
• Angle of seat
• Height of backrest
• Angle of backrest
• Seat slides forward or backward
• Arm rests move up/down and in/out

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. I have found it 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. Currently I use a support called TruComfort, which I have found to be very helpful. It was recommended by my Alexander teacher.

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'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. 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.

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.

Setting up your workstation

There are three pieces of equipment that require special attention:

1. Keyboard: positioned above your thighs, you shoulder be able to reach the keys with your elbows at your side and bent at (perhaps slightly greater than) 90 degrees, and your forearms roughly parallel to the ground;
2. Mouse: just to one side of your keyboard, so that you don't have to lean, stretch, or hunch to work it. Many people have one shoulder noticeably lower than the other - this can be caused by repetitive stretching for a mouse;
3. Monitor: directly in front of you (not off to the side), such that your eye level is somewhere between the top of the screen and 20% from the top. The screen should be about 15-25 inches from your eyes.

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.

Proper technique: typing, mousing, and writing

There are three keys to proper typing technique.

1. Keep your wrists straight: the straighter your wrists, the less strain you put on the tendons and nerves that run through your wrist. A split keyboard may aid you in keeping your wrists straight.
2. Let your hands float: This means don't rest your wrists on the desk, keyboard, or a wrist rest when you are typing. Let them hover over the keys. This has three advantages: (i) You allow the big muscles in your back to share some of the work; (ii) It allows you to keep your wrists straight, which is impossible if they're planted on a wrist rest; (iii) It's easier to reach the hard-to-reach keys (next item).
3. Don't strain your fingers: When you need to press a hard-to-reach key, like CTRL, SHIFT, BACKSPACE, etc., don't stretch out your pinky. Instead, move your whole hand and use your index or middle finger to press the key. Don't use one hand when you need to hit two keys simultaneously, e.g. CTRL-X, SHIFT-Y. Think before you type: unnecessary retyping/editting can add up. Use a light touch when typing: don't pound the keys.

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. You can find Dvorak typing tutors online.

Using a mouse can be even more harmful than typing. Here are three reasons why this is so:

• All the work is done by one finger. Double clicking and dragging can be especially straining.
• Modern windows-based machines rely heavily on the use of a mouse.
• Users often do not position the mouse properly. Instead, they stretch for the mouse, which can lead to increased strain, a drooping shoulder, and pain extending up into the shoulder and neck.

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.

Standard mouse

Trackball

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.

Stretching and strengthening

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 Yoga Journal and Core Awareness.

Ten easy ways to reduce your risk of developing RSI

1. TAKE BREAKS! when using your computer. Every hour or so, get up and walk around, get a drink of water, stretch whatever muscles are tight, and look out the window at a far off object (to rest your eyes). As explained in above,
2. Use good posture. If you can't hold good posture, it probably means it's time for you to take a break from typing. If you are perpetually struggling to maintain good posture, you probably need to adjust your workstation or chair, or develop some of the support muscles necessary for good posture.
3. Use an ergonomically optimized workstation to reduce strain on your body.
4. Exercise regularly. Include strengthening, stretching, and aerobic exercises. I find yoga and Pilates especially helpful.
5. Only use the computer as much as you have to. Don't email people when you could walk down the hall or pick up the phone and talk to them. It's not only better for your hands - it's friendlier. Think before you type to avoid unnecessary editting.
6. Don't stretch for the hard-to-reach keys, e.g. BACKSPACE, ENTER, SHIFT, CONTROL... basically everything but the letters. Instead, move your entire hand so that you may press the desired key with ease. This is crucial when you are programming or typing something in LaTeX, where non-letter keys are used extensively.
7. Let your hands float above the keyboard when you type, and move your entire arm when moving your mouse or typing hard-to-reach keys, keeping the wrist joint straight at all times. This lets the big muscles in your arm, shoulder, and back do most of the work, instead of the smaller, weaker, and more vulnerable muscles in your hand and wrist. If you find it difficult to do this, then your shoulder and back muscles are probably too weak. It is OK, and in fact a good idea, to rest your elbows/wrists when you are not typing.
8. Use two hands to type combination key strokes, such as those involving the SHIFT and CONTROL keys.
9. When writing, avoid gripping the writing utensil tightly. Someone should be able to easily pull the writing utensil out of your hand when you are writing. If your pen or pencil requires you to press too hard, get a new one (my favorite is Dr. Grip Gel Ink)
10. Realize that you are not invincible. RSI can happen to you. Don't be afraid to ask for help.

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If you develop RSI

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.

STOP TYPING!(?)

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.

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.

When to seek help

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.

Finding a good doctor or therapist

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.

Relief

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, 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 sprot, 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).

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 (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.

Surgery?

Is surgery ever the right choice? Well, I'm not a medical doctor, so I can only speak from my experience. I did not have surgery, nor did I ever consider it. Yet many people choose to undergo surgey for RSI. Does it work? If successful, it will probably alleviate pain in the short term. But if you do not change your habits, I see no reason why your problems won't return.

Consider this: 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. Now, I play tennis and the banjo regularly. 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 for my lifestyle, it's as much recovery as I could have hoped for. For me, not having surgery was definitely the right choice.

Recovery and maintainence

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.

1. Rest as much as possible (from the activity causing your injury). Many aspects of your injury can only heal with rest and time.
2. Excercise regularly, including stretching and strengthing of core muscles (abs, gluts, hamstrings, etc.). For some specific stretches, see the section on stretching and strengthening. I have found yoga and Pilates to be beneficial. Aerobic excerise is good as long as it doesn't aggravate the injury.
3. Find a good doctor and stick to his or her program for you.
4. Work hard to develop discipline regarding your posture and typing habits.
5. Be patient and persistent.

Voice activated software

There are several voice activated applications intended for document composition. I have used 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, wasn'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:

• Dragon Systems (NaturallySpeaking and DragonDictate)
• IBM (ViaVoice)
• Lernout & Hauspie Speech Products formerly Kurzweil Applied Intelligence (Voice Xpress)
• Conversational Computing Corporation (Conversa Web)

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 (I'm not sure). 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.

Coping with RSI

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. Universities often have Counseling Centers that are free to students.

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Additional resources

Resources for 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.

Two must read books

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).

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.

Online resources

• Harvard RSI Action, where I got the idea (and some of the content) for this web page. A variety of perspectives on RSI, and lots of advice for those dealing with serious RSI problems.
• RSI Program: Collection of RSI resources maintained by the authors of It's Not Carpal Tunnel Syndrome! (see above)
• RSIHelp: Deborah Quilter's site.
• If you want more information on prevention, a really good place to look is Paul Marxhausen's RSI page, with even more pictures and even some mpeg videos. There are also references to good books on prevention, including easy links to on line book stores so you can order them right now.
• The Typing Injury FAQ is a gold mine of information. If you are looking for information about ergonomic devices, these archives are a good place to start.
• IBM's Healthy Computing website is an excellent and comprehensive guide to computer ergonomics.
• Amara's RSI Page contains prevention and background information on RSI.
• The OSHA web page is the best place to start for scientific or statistical documentation on RSI.
• Sandra Day O'Connor's opinion from Toyota v. Williams.
• www.repetitivestraininjury.org.uk