Amara's RSI

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Last Revision: 22 November 1995.
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Ergonomic Computing

(or Don't Let Your Computer Cripple You!)

An essay by Amara Graps

RSIs are an Enormous Problem

"It's epidemic."

This doctor's response was to my question: "What percentage of yours and your collegues' patients have injuries caused by computer usage?"

Surprised? Look around at the computer users you know, and ask them if they have experienced pain and weakness in their hands and arms, especially after long hours of days/weeks/months in front of a computer. I believe their answers will bear out the doctor's claim.

But in case you don't believe me, let's look at the U.S. Bureau of Labor Statistics:

================================================
Year     # of RSI cases    % of all illnesses
================================================
1978        20,200                14%
1979        21,900                15%
1980        23,200                18%
1981        23,000                18%
1982        22,600                21%
1983        26,700                25%
1984        37,700                28%
1985        37,000                30%
1986        45,500                33%
1987        72,900                38%
1988       115,300                48%
1989       146,900                52%
1990       185,400                56%
================================================

I will examine this unfortunate side effect, Repetitive Strain Injury (RSI), of the Digital Age in this essay. It has probably affected someone you know. I hope this information will cause you to pause, look at your computer setup and initiate changes that make your computing safer and more comfortable. And if you've already experienced some of RSI's disabling and career-threatening effects, I hope that this article eases some of your anxieties by describing methods, approaches and treatments that have helped others.

Definition and Symptoms

RSI ( also known as RMI, repetitive movement injury, OOS, occupational overuse syndrome, and cumulative trauma disorder, CTD) is a a description, and not a diagnosis. It is a grab bag term which has many causes and many manifestations. Carpal tunnel syndrome, CTS, is a specific condition, and therefore a diagnosis. It is this sort sort of semantic confusion which leads to the very misleading "RSI does not exist" tabloid stories.

The many diagnosable disorders that RSI encompasses include carpal tunnel syndrome, ulnar nerve entrapment, deQuervain's syndrome, thoracic outlet syndrome, tennis elbow, and tendonitis (see explanations of many of these disorders in the glossary at the end of the article).

An RSI develops slowly and can affect many parts of the body. Many symptoms may come and go before settling in: aching, tenderness, swelling, pain, cracking, tingling, numbness, loss of strength, loss of joint movement, and diminishing coordination of the injured area. These symptoms can then lead to the disorders listed above. Users should stop whatever is causing any symptoms and see a doctor AS SOON AS POSSIBLE. The difference of a day or two can mean the difference between a short recovery and a long, drawn-out ordeal.

Causes

The causes of RSI are controversial. While every RSI sufferer knows that a stressful day will worsen their symptoms, simply by increasing muscle tension and thereby pain, RSI is definitely not "all in the mind". The spread of RSI within a workplace may even be exacerbated by anxiety once a few people have RSI, but anxiety is not sufficient to cause RSI. Rather, RSI is caused by many shared and individual factors, including physical fitness, muscle tension, individual work habits, stress, long hours, lack of breaks, bad ergonomics, and poor, static posture.

One of the greatest risk factors leading to RSI is the restriction of circulation to muscles, tendons, and nerves during repetitive use. During static contraction (hold your arm out to the side, say), circulation is nearly stopped, which is why you can't do it for very long. The oxygen gets used up. During repeated contractions the effect is just delayed. Under the kind of demands we place on our bodies during computing, these tissues need all of the nutrients and oxygen they can possibly get from our blood. Also, the blood must flow freely to carry off the additional waste products (which cause pain) - lactic acid and carbon dioxide - produced by said use.

Other factors constrict blood flow to your extremities, setting up a vicious cycle. One factor is any existing injury. Injured tissue inflames during repetitive motions. This pressure limits circulation. Then, once one muscle hurts, all its neighbors tense up, perhaps to relieve the load. This makes sense for your normal sort of injury, but it only makes things worse with repetitive motion. More tension means less blood flow, and the cycle continues.

Treatment

So you've decided to see your doctor because you suspect you have an RSI. What kind of treatment can you expect?

A typical first-time treatment is a prescription for ibuproben, a wrist-brace, and instructions to ice and rest the affected area. Additional treatment may include physical therapy. If none of this helps, you'll most likely be sent to a specialist, a surgeon, for possible surgery. A rather bleak scenario, in my opinion.

What can you do?

Be proactive and involved in your treatment. Realize that your doctor may not know much more than you about the specifics of your injury and the kind of treatments to try. One fact is clear: there is little agreement among doctors on effective treatments. If you wish a complete recovery, then it will be up to you.

The following therapies, treatments and disciplines have helped many people with a RSI. They fall into the following three categories.

Ergonomics to prevent further injury;

Habits which heal and promote health; and

Help to restore health.

I will discuss ergonomics in some detail later on. First, I will discuss habits which heal and promote health.

Habits for Healing and Promoting Health

Promoting habits for healing and health is a matter of personal taste. Investigate and learn what works for you. Good methods to try are the following.

For more effective posture, breathing, and coordination: Try the Feldenkrais method or the Alexander technique.
For stretching and gentle body movement: Try Yoga, Chi Kung, Ba Duan Jin, or Tai Chi.
For reducing stress (which can cause a large negative physical reaction): Try meditation, visualization excercises, taking deep breaths, sensory deprivation tanks,or going for a walk.
For learning to let go of neck, shoulder and upper back muscles: Try biofeedback.
For working through sore, stiff, or sensitive muscles: Try massage, physiotherapy, trigger point therapy, acupressure or shiatsu.
For vitamin therapy: Try 200 mg./day of B6. Anti-oxidant vitamins E, C, and beta carotene have also helped some people.
For inproving nutritive intake: Try cutting out sugar.
For keeping your hands warm and flexible: Try wearing Handeze or some other fingerless gloves. Squeezing rubber racketballs, working with soft putty, or playing with Chinese health balls throughout the day have also helped many people.
For increasing hand vitality and working through soreness: Try warm-cold contrast baths.
For reducing inflammation and pain: Try ice or a package of frozen vegetables (like peas) on the affected area.
For relieving neck strain after sleeping: Use a cervical roll and don't sleep on your stomach.
For general well-being: Take frequent rest breaks (recommended is 5 min rests every 20 min or better yet, a thirty second break every three minutes, and get up out of your chair at least once an hour), drink lots of water, excercise, stretch, and move around often, and sleep well.

Some Posture Guidelines

Let your shoulders relax.
Let your elbows swing free.
Keep your wrists straight.
Pull your chin in to look down - don't flop your head forward.
Keep the hollow in the base of your spine.
Try leaning back in the chair.
Don't slouch or slump forward.
Alter your posture from time to time.
Every 20 minutes, get up and bend your spine backward.

Help to Restore Health

Conventional medicine mostly addresses treating the symptoms. We need to focus on the causes and view the body as a complete system. You will have to go through some trial-and-error to find a specialist that practices a skill that works for you since each repetitive injury case is different. My observations of other injured people are that the following doctors (who take a 'whole-body' approach) have been helpful to various individuals: Osteopaths, Chiropractors, Occupational Therapists, Physical Therapists, Kinesiologists, Physiatrists, Acupuncturists, Bonnie Pruden therapists, and Massage Therapists.

An aside- Wrist Braces

Wrist braces can be a help, or a painful hindrance. Their effect depends on the diagnosis and if the possible cause of overload is bad wrist posture. The main rule of thumb is to pay close attention to how your hand and wrist feels, and if it's causing you to work against it, don't wear it. My personal experience, and that of some specialists, is that it isn't a good idea to wear wrist braces while you are actively using your hands, only when your hands are resting or passive, such as when you're asleep.

Workstation Ergonomics

RSI and associated poor ergonomics not only affect the health of computer users - they hit the finances of their employers as well. One direct cost is a productivity loss of 20 per cent in keying at an unergonomic workstation, according to one study. A Norwegian company discovered the indirect costs by redesigning assembly workers' workstations, reducing RSI - it made an 840 per cent return on its investment, simply by reducing the cost of sick leave and staff turnover.

Right-angle Rule

The basic principle behind a ergonomically-sound workstation setup involves right angles. Your feet should rest flat on the floor, your calves should be perpendicular to the floor and to your thighs, which should be parallel to the floor, and the angle between your thighs and back should be at least 90 degrees. Your arms should hang relaxed at your sides, and your forearms should project out straight in front of you, forming another 90 degree angle. Your wrists should be straight, not arched upward. You might adjust your keyboard for this, or you might have to adjust your chair and desk height. Standard typing height is supposedly 27 inches, but that will vary with your height.

Armrests

The use of armrests on chairs is a controversial subject in the ergonomics community. Ulnar nerve entrapment can result from resting forearms and elbows against hard surfaces, like some armrests. However, an armrest can provide some support if you are already injured, as long as the armrest is well-padded, and it's not forcing your shoulders up and preventing you from relaxing your upper body. My personal experience with armrests are that, as I healed, I found them to be more of an impediment than a help, and so I rarely use them nowadays.

Monitor Placement

For distance from your monitor, you should be between 18 and 28 inches away from your screen, and the screen should be adjusted so that it is between 15 and 30 degrees below your straight-ahead line of sight. If the screen is much lower than that, you'll probably end up slouching.

Alternative input devices

Look into alternative input methods that will reduce strain on your hands and wrists. Many heavy computer keyboardists have found the split and adjustable keyboards to be more comfortable. The most common alternative input device is the trackball, but the new "trackpad" is generating alot of interest and converts these days too.

More esoteric input devices include chord keyboards and voice recognition systems. Chord keyboards may help reduce CTS problems because you don't have to move your hand at the wrist to reach all the keys. Voice recognition systems are powerful, but both you and the software will have to train each other. You will need to learn ways of speaking to not strain your voice, and the software will have to be trained to recognize your speaking patterns.

Wrist Pads

Wrist pads/rests are usually the neoprene pads that many people put in front of their keyboards. The wrist pads help in two ways. First, the wrist pad is designed to remind you to lift up your wrist slightly so thtat your hands don't rest on any surface as you type, because that angle can compress the carpal tunnel. Secondly, when you pause in your typing, you probably put your hands down, and it's better to rest them on a soft pad than on the hard corner of a desk, which can cut off circulation and compress the carpal tunnel. However, please keep the following thought in mind with regard to wrist rests: Don't rest your wrist on your wrist pad as you type! Many people are never told how to use wrist rests properly, so they slide their poor injured wrists along the padding, further exasperating their injury.

The Chair

The chair is probably your most important piece of ergonomic furniture. The following are the basics.

Tilt the seat pan to get your thighs slightly higher than your knees. This straightens the spine and helps support your head and arms.
Check that the seat pan is in contact with your thighs but not touching the inside of your knees. (You run the risk of cutting off circulation in your legs.)
Check that the seat pan is not so deep that your back doesn't make contact.
Check that your chair has a tiltable back. Ergonomic wisdom says that you should not sit bolt-straight, but a little back (no more than 10 degrees). Let the chair take a little bit of your weight.
Adjust the height of the seat so that your thighs rest on the seat pan *plus* places your feet firmly on the floor. If you have to be higher to get in the right relationship to the desk or the keyboard, then use a footrest.
(If you want armrests.) Check that the armrests are not too wide apart. Too wide leads to more ulnar deviation at the wrist.
(If you want armrests.) Check that the armrests are not too close together. Too close together interferes with your arms during typing.
(If you want armrests.) Check that the armrests are not too high. You don't want the armrests to force your shoulders up because it leads to Thoracic Outlet problems, and neck and shoulder tightness.
(If you want armrests.) Check that the armrests are not too low. Too low leads to a rounding of the spine, contraction of the chest, and restricted breathing.
(If you want armrests.) Check that the armrests not too hard. If its too hard, it puts pressure on ulnar nerve at the cubital tunnel at the elbow.

Those are the basics. The most important thing to ask yourself is: Are you comfortable throughout a day's work? If it feels good and you tend not to shift trying to get comfortable, then you are probably less at risk of injury (reinjury).

And remember - we're not robots. Move around. Get up. A good chair lets you have a little room to move so you can stay loose. Leaning and slumping is OK once in a while. Just don't make that your continual working position.

Some RSI Resources

RSI Network Newsletter

Is a bi-monthly online newsletter produced by Caroline Rose and distributed online by Craig O'Donnell. Subscribe by sending email with any subject to:

			majordomo@world.std.com	

			with the message body reading:

			subscribe rsi

Some Anonymous FTP & Gopher sites

ftp.std.com; gopher or anonymous ftp;
/pub/boston-rsi for the Boston RSI archive
/pub/rsi for the RSI Network Newsletter

ftp.csua.berkeley.edu; anonymous ftp;
/pub/tuping-injury; Extensive RSI info!

Some World Wide Web sites related to RSIs

Some Listserv Mailing Lists

Sorehand:
Sorehand is a San Francisco-based listserv mailing list for people with RSIs. Subscribe by sending email with any subject to:

            listserv@vm.ucsf.edu	

            with the message body reading:

            subscribe sorehand Your Name

RSI-East:
RSI-East is the east coast's answer to Sorehand. Subscribe by sending email with any subject to:

            listserv@sjuvm.stjohns.edu

            with the message body reading:

            subscribe rsi-east Your Name

Newsgroup: Sci.med.rsi

Sci.med.rsi is an unmoderated newsgroup for the discussion of all aspects of Repetitive Strain Injuries. RSIs have many causes, with computing equipment playing a major role. Everybody in the online community who uses a keyboard or a pointing device is at risk for developing an RSI.

Topics relevant for discussion include but are not limited to:

Prevention through improved ergonomics.
Diagnosis of injuries.
Treatment of injuries.
Workmen's compensation, insurance, and other legal issues.
Product reviews.
Publication of other relevant newsletters.
Offering support to fellow RSI sufferers.

Miscellaneous Sources

Ergonomic equipment in Mt. View, CA:
Stephen A. Marshall
Ergonomic Sciences Corp.
2672 Bayshore Parkway, Suite 520
Mountain View, CA 94043
415-964-3135

Ergonomic Training in the SF Bay area (CA):
Gary Karp
Onsight Technology Education Services
Ergonomics consulting/evaluation/tools
1510 Eddy Street, Suite 1511, San Francisco, CA 94115
415/749-1983, fax) 415/292-7822, gkarp@sirius.com

Physiatrists: American Academy of Physical Medicine & Rehabilitation: 312-922-9366

Osteopaths: American Academy of Osteopathy: 317-879-1881

Incomplete Glossary

Abduction:: Moving away from the body.
Alexander technique:: This concentrates on improving the use we make of our bodies. Alexander teachers can help RSI sufferers correct the habits that result in poor posture and muscle tension in computer work and other activities.
Ba Duan Jin:: These Chinese exercises were invented several thousand years ago and used by monks and soldiers to improve their strength and health. Ba Duan Jin employs gentle stretching to stimulate the blood circulation and relieve any aches or pains.
Chi Kung:: This Chinese discipline, which is related to Tai Chi Chuan, involves standing in certain positions that enhance the 'chi' or energy. It is very useful for short term pain relief and long term healing, and can also be used to prevent work-related health problems.
CTD:: Cumulative Trauma Disorder -- another synonym for RSI.
CTS:: Carpal Tunnel Syndrome (see below).
Feldenkrais Method:: A system of gentle exercise and hands-on manipulation that encourages more effective posture, breathing, and coordination.
Hyperextension:: Marked bending at a joint.
OOS:: Occupational Overuse Syndrome -- synonym for RSI.
Overspanning:: Opening the fingers out wide.
Physiotherapy:: This involves mobilising the neck and upper back, which are usually stiff in cases of RSI, together with 'neural stretches' to lengthen contracted nerves, which appear to cause pain in some forms of RSI.
Pinch grip:: The grip used for a pencil.
Power grip:: The grip used for a hammer.
Pronation:: Turning the palm down.
Radial Deviation:: Bending the wrist toward the thumb.
Relaxation techniques:: There are many approaches to relaxation, often based on deep breathing using the diaphragm, that help to soften tense muscles and reduce fatigue.
RSI:: Repetitive Strain Injury - a general term for many kinds of repetitive motion injuries.
Supination:: Turning the palm up.
Trigger point therapy:: This is superficially similar to acupressure or shiatsu but also employs stretching and exercise. It immediately relaxes muscles that are in spasm, and can also help back ache and migraine. Some physiotherapists practise this in the UK, but a comprehensive book and self treatment tools are also available from the US.
Ulnar deviation:: Bending the wrist towards the little finger.
Wrist extension:: Bending the wrist up.
Wrist flexion:: Bending the wrist down.

Types of Injuries

Injured areas come in two main types: Local conditions and diffuse conditions. Local problems are what you'd expect: specific muscles, tendons, tendon sheaths, nerves, etc. being inflamed or otherwise hurt. Diffuse conditions, often mistaken for local problems, can involve muscle discomfort, pain, burning and/or tingling; with identifiable areas of tenderness in muscles, although they're not necessarily "the problem."

(Note: most injuries come in two flavors: acute and chronic. Acute injuries are severely painful and noticable. Chronic conditions have less pronounced symptoms but are every bit as real.)

Adverse Mechanical Tension:: Also known as 'neural tension', this is where the nerves running down to your arm have become contracted and possibly compressed as a result of muscle spasms in the shoulders and elsewhere. AMT can often misdiagnosed as or associated with one of the other OOS disorders. It is largely reversible and can be treated with physiotherapy (brachial plexus stretches and trigger point therapy).
Carpal Tunnel Syndrome:: The nerves that run through your wrist into your fingers get trapped by the inflamed muscles around them. Symptoms include feeling "pins and needles", tingling, numbness, and even loss of sensation. CTS is often confused for a diffuse condition.
Tendonitis:: An inflammation of a tendon. Repeated tensing of a tendon can cause inflamation. Eventually, the fibers of the tendon start separating, and can even break, leaving behind debris which induces more friction, more swelling, and more pain. "Sub-acute" tendonitis is more common, which entails a dull ache over the wrist and forearm, some tenderness, and it gets worse with repetitive activity.
Tenosynovitis:: An inflamation of the tendon sheath. Chronic tenosynovitis occurs when the repetitive activity is mild or intermittent: not enough to cause acute inflamation, but enough to exceed the tendon sheath's ability to lubricate the tendon. As a result, the tendon sheath thickens, gets inflamed, and you've got your problem.
Thoracic Outlet Syndrome (TOS):: Is a compression of nerves and vessels between the neck and shoulders--possibly caused by hunched or raised shoulders. (Could also be caused by extra rib.) Symptoms include pain in wrist/hand, just like carple tunnel. Lack of pulse in affected arm. Last two fingers of affected hand can be numb, or tingle. Also can turn blue due to lack of blood.

References

Pascarelli, Emil and Deborah Quilter, "Repetitive Strain Injury: A Computer User's Guide," Wiley, 1994.

R. Henning, S. Alteras, P. Kacques, G. Kissel, A. Sullivan, "Frequent, Short Breaks During Computer Work, The Effects on Productivity and Well Being in a Field Study, " University of Connecticut.

Pinsky, Mark A., The Carpal Tunnel Syndrome Book, Warner Books, 1993.

Sellers, Don, Zap!, Peachpit Press, 1994.

Montgomery, Kate, Carpal Tunnel Syndrome, Sports Touch Publishing, 1992.

Engst, Adam & Tonya, TidBITS#134/20-Jul-92.

Rose, Caroline (producer), The RSI Network Electronic Newsletter.

Donkin, Richard. (1994) "Typing Injury FAQ: Software Monitoring Tools" Usenet news.answers. Available via anonymous ftp from rtfm.mit.edu in pub/usenet/news.answers/typing-injury-faq/software. 8 pages.

Wallach, Dan S. (1994) "Typing Injury FAQ: General Info" Usenet news.answers. Available via anonymous ftp from rtfm.mit.edu in pub/usenet/news.answers/typing-injury-faq/general. 7 pages.

Wallach, Dan S. (1994) "Typing Injury FAQ: Keyboard Alternatives" Usenet news.answers. Available via anonymous ftp from rtfm.mit.edu in pub/usenet/news.answers/typing-injury-faq/keyboards. 14 pages.

Valuable contributions for this article came from the Sorehands mailing list and the RSI Network newsletter. The following contributors in particular have provided good information: Alan K. Jackson, Debbie Stiles, Michael Krugman, Adam and Tonya Engst, Joy Linn, Chris Moore, Dan Wallach, Linda Lamb, Martin Fouts, Philippe Bourgois, John Lamp, Gary Karp, Craig O'Donnell, Pete Johnson, Janet Alexander, Richard Donkin.

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Last Modified by Amara Graps on 22 November 1995.
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