RSI Demystified

I know I haven't blogged in a while. It's not that I've been busy. Things just seem to be the same each week, so there hasn't been anything new to write about. But I promised myself I'd blog whenever I finished reading a book, and I actually finished reading two books recently.

Stress Book
Most recently, I finished a phenomenal book called "Why Zebras Don't Get Ulcers," by Robert Sapolsky.

It explains the science of stress, both physiological and psychological, which can be summed up like this: The body responds pretty much the same way to any kind of stressor. And it responds in the way that would most help you escape from being eaten by lions--directing your energy into short-term survival mechanisms, and diverting it from long-term repair. Which is great if you're being eaten by lions. Not that being eaten by lions is great. But if you spend enough of your life stressed out about finances, looming deadlines, etc., your body's natural response to these prolonged stressors is going to have serious consequences for your physical health.

Anyway, Sapolsky's book is a fascinating tour of the human body, as examined through the lens of stress and the body's response. And every page has the kind of gem that leaves you needing to stop and share some cool fact with whoever's nearby. (Poor Virg.)

Virg bought the book for me last winter, which I guess was her way of saying I was too stressed. Now that my job is far less demanding, she thinks I've been much happier and much less stressed. Maybe the book helped me focus my career plans on the kinds of jobs that wouldn't work me to death and stress me out so much.

RSI Books
Anyway, the other book I finished recently was called "Comfort At Your Computer" by Paul Linden. It was a rather unenjoyable read, but one that was necessary to get some genuinely helpful tips on ergonomics.

I've been suffering from computer-related (and piano-related?) RSI (repetitive strain injury) pains in my wrists since February, and it's been very frustrating experiencing these pains, unable to do the things I enjoy most, and unable to get any real help. I endured a few months of worthless appointments and treatments before I started researching RSI on my own. I've now read several books on the subject, including:

• "It's Not Carpal Tunnel Syndrome" by Jack Bellis and Suparna Damany
• "Dr. Pascarelli's Complete Guide to Repetitive Strain Injury" by Emil Pascarelli
• "The Trigger Point Therapy Workbook" by Clair Davies
• "Conquering Carpal Tunnel Syndrome And Other Repetitive Strain Injuries" by Sharon Butler
• "Comfort At Your Computer" by Paul Linden

What is RSI?
If you had to start with one of these books, I'd go with "It's Not Carpal Tunnel Syndrome." The title reflects everyone's tendency (including several of my misinformed doctors) to diagnose you with carpal tunnel syndrome (CTS), no matter what your symptoms are. RSI is a very general term for the kind of pain I have, while CTS refers to a very specific medical condition. It turns out that the muscles that operate your fingers are located primarily in your forearm, and they pull on your fingers by means of long cables called tendons. Many of these tendons reach the hand through a narrow tunnel in the wrist called the carpal tunnel. The median nerve, which serves the thumb, index finger, and middle finger, also passes through the carpal tunnel. When the carpal tunnel is compressed, or full of fluid, it compresses those tendons and the median nerve, which prevents signals from the thumb-side of your hand from reaching your brain. So, if you regularly feel numbness or tingling in this part of your hand, then you may have CTS.

CTS occurs in people who have narrow carpal tunnels, people with overactive glands, pregnant women, etc. Its link to repetitive activity is unclear, but certainly many computer users have suffered from the symptoms of CTS. Surgery is often proposed as the solution for such people. The surgeon cuts the wall of the carpal tunnel (a ligament), which gives the tendons and median nerve more room. This immediately alleviates the symptoms for many people suffering from CTS, but it's not clear that it's a good long-term solution. At the least, surgery should probably be a last resort.

I don't suffer from CTS symptoms, but I do experience numbness at times, particularly in my pinky and ring finger--a sure sign that my ulnar nerve is being compressed somewhere. RSI pain is also caused in large part by compression. I'm still learning about RSI, but here's my current understanding of this condition.

Imagine a device that looks like a long tube.

picture of a device that looks like a long tube,
so you don't have to imagine too hard

When you turn on the device, the tube contracts, which is really cool, except that when it contracts, it's got all this disgusting goop that oozes out the sides. Thankfully, the device also comes equipped with hoses that suck up the goop and carry it away to some sort of appropriate goop waste receptacle.

contracted tube device
(de-gooping hoses not shown)

Now, suppose you've got two big heavy blocks, and you want to pull them together. You get a whole bunch of contracting tube devices, and you connect them to the blocks. Then you turn them all on at once, and the blocks are pulled toward each other.

a series of tubes,
pulling big heavy blocks together

What could go wrong? Well, suppose you turn on these contracting tube devices a whole lot. That will cause a lot of goop to ooze out the sides. But that's no problem, because the hoses will make sure the goop is properly removed. Ah, but what if something crushes one of those hoses, so that it can no longer remove as much goop? Well, that's no problem, as long as you don't turn on the contracting tube devices much, so that they don't generate too much goop.

But what if you turn on the devices a whole lot, when that hose is crushed? Then something very bad happens, because lots of goop oozes out of the tube with the crushed hose, and since it's got nowhere to go, the goop gooks up the contracting tube device. If the goop is allowed to accumulate like this for a while without being removed, that contracting tube device breaks down, getting stuck in a contracted setting. So now the broken tube is pulling unevenly on the block. Thankfully, this particular block is equipped with state-of-the-art sensors which detect this uneven stress and respond by illuminating a helpful warning light.

warning light comes on when block is pulled unevenly by gooked-up tube

Have you figured out what all this silliness has to do with RSI? Those contracting tubes are your muscle fibers. The goop is the metabolic waste generated when your body uses energy to contract its muscles. The hoses are the blood vessels and other channels that carry away that metabolic waste. The block those muscles are pulling on is your wrist. And the warning light is the pain you feel in your wrist.

Bad Advice
See a doctor for RSI pains and they'll immediately diagnose you with carpal tunnel syndrome, and then tell you to wear wrist splints and take Advil. But this is terrible advice, because the splints will compress your muscles and keep that goop in place, and will limit your range of motion so that you're using the same muscles repeatedly, and will deceive you into thinking you can continue working without changing your work habits. And that Advil won't help, because you're not suffering from an inflammation, and the quantities of Advil you'd need to consume in order to reduce the constant dull pain would destroy your stomach lining. The doctor will also advise you to stop using the computer--the equivalent of telling you to simply stop using that contracting tube system. This just avoids the problem instead of fixing it. And it isn't realistic advice if your life is in computers. I have seen nearly a dozen doctors, and not a single one of them had any understanding of RSI. But they were able to prescribe physical therapy.

Physical therapists are well meaning people, but many are equally misinformed. They push all sorts of silly remedies, including ice packs, hot packs, icy hot cream, and electrical stimulation--all of which temporarily relieve the pain (like covering the warning light with a blanket), but they do nothing to solve the underlying problem. They push other bad solutions, too, like strengthening your wrists (which is like making the tube devices pull even heavier blocks), stretching your wrists (stretching the blocks), and massaging your wrists (cleaning goop off the blocks).

Good Advice
But no one understood enough to go after the real problem: all that goop that's gunking up the contracting tube device. Cleaning that goop is relatively easy. It requires deliberate, targeted, deep-tissue massage. This is something you can even do by yourself, although finding that gunked up spot is tricky. Since the wrist is controlled by muscles in the upper half of the forearm, it's a good bet that you'll need to work on muscles in that region--an area that not one of the 20-or-so physical therapists and doctors I saw ever examined. And it turns out that you can relieve the pain quite effectively in this manner. The "Trigger Point Therapy Workbook" suggests using a lacrosse ball, and rolling your arm over the ball against a wall, and this has proven to be very helpful. Unfortunately, this only cleans out the goop temporarily. Go back to using a computer, and the goop returns, and you find yourself spending a lot of time with a lacrosse ball.

The real problem is that compressed hose--the blood vessel that isn't removing metabolic waste products from your muscles fast enough. What's compressing that hose? (Or if you've got numbness and tingling sensations, what's compressing that nerve?) Unfortunately, the answer is probably other tight knotted muscles. And those muscles are probably tight because their hoses are compressed by other tight muscles. So, to relieve pain in your wrist, you will almost certainly need to work on muscles in your upper arm, shoulders, neck, and upper back. And as you work on these muscles and relieve various tight spots, you'll almost certainly feel your pain move around.

Trigger Points
That "Trigger Point Therapy Workbook" does a good job at pointing out what muscles are likely to contribute to pains in other muscles. If your muscle fibers get gunked up enough, they develop trigger points--muscle knots that refer pain to other locations. That is, when you press on the trigger point, you actually feel the pain travel to some other part of your body. Trigger points are responsible for all kinds of pain, including some migraine headaches. Why? Most likely because if the muscles in your neck get really tight, they can pull unevenly on your skull, thereby causing your nerves to send warning messages to your brain, in the form of pain.

Virg suffers from frequent terrible migraines. I gradually convinced her to look into trigger points, and sure enough she can actually simulate a headache by pressing on certain spots in her neck muscles. So for the past month, she's been seeing a very wonderful and knowledgeable massage therapist just a minute from our home, and he is indeed finding lots of trigger points. What causes them? Most likely, holding your head in an awkward position to look at a computer screen, and whiplash--something both of us have suffered from in the not-too-distant past.

Virg convinced me to see her massage therapist, and he's been very effective in relieving my muscle tightness. These aren't your typical massages. They're not about relaxing. They're more like intense medical treatments, where I'm regularly communicating with the massage therapist, helping him find the tight spots, and learning what I can do to work on myself. He's a big fan of stretching to relieve muscle tightness, and he's been very helpful in identifying which particular areas require stretching.

So, what's being compressed? In my case, and in many other RSI cases, the answer is most likely the thoracic outlet--the region below the collarbone and above the ribs, where the brachial plexus (the bundle of nerves that serve your arm) and subclavian artery pass through various muscles on their way from your neck to your arm.

Thoracic Outlet
(image stolen from Wikipedia)

What could compress this region? Frequent chest-breathing. Tight scalene muscles in the side of the neck, pulling your rib up against your collarbone. Tight pect muscles. All of which cause and are caused by: working hunched over. In other words, bad posture. Stretching out this region and massaging tight spots in these muscles is critical to relieving the problem, but it's just going to come back unless you practice good posture.

Posture and Ergonomics
There is a lot of bad advice out there about posture and ergonomics. Any office HR manager with 15 minutes of ergonomics training will tell you to sit up straight with your chest out, and with your elbows, waist, and knees at right angles. And beware of any product that calls itself ergonomic: every curved keyboard, awkward mouse, and fancy chair. So what is good posture/ergonomics?

Sitting hunched over has two negative outcomes. It compresses areas like your thoracic outlet, and it puts great strain on your upper back and neck muscles, which have to hold your head up in that awkward forward position. Therefore, good posture is all about preventing this compression and keeping your head properly balanced on top of your spine. Nearly everything I've learned about good seated posture has come from the "Comfort At Your Computer" book, and I'm finding it really works.

Good posture begins with your legs. Sit on a flat, padded chair, so that your knees are level with, or slightly lower than, your waist. Your feet should be flat on the floor, shoulder width. Why do you care so much about your legs? Because the more weight you put on your legs and feet, the less work your back, shoulders, and neck will have to do. Most "ergonomic" chairs slope backward, encouraging you to recline. But reclining is bad, because it causes you to hunch forward to reach your keyboard and look at the screen. If anything, you want a chair that slopes slightly forward, allowing you to put more weight on your feet.

The real key to sitting comfortably is the pelvis. If you sit down and allow your pelvis to tip backward, you'll notice that your spine will curve so that your shoulders and neck slump forward. This is bad. Instead, tip your pelvis forward, and your spine straightens out, letting you move your shoulders and neck back into a more relaxed position. The author suggests you tip your pelvis forward by consciously "pointing your genitals downward." I know it's really icky to think about genitals when you're trying to work, but it's surprisingly effective in positioning your spine, shoulders, and neck. It's also difficult to maintain this position for long, and that's where a rolled-up towel comes in. Position it so that it helps tip your pelvis forward, and you can sit in this position quite comfortably.

one frood who really knows where his towel is
(image stolen from Amazon, who stole it from the "Comfort At Your Computer" book)

All of this is so that you can move your shoulders back, and let them relax so that your shoulders drop backward comfortably. It also lets you position your head so that it sits on top of your neck, pointing downward just a tiny bit. You also want to sit with your upper arms at your sides, and your hands positioned comfortably in your lap. If you've got a chair with armrests, you'll find they cause you to scrunch your arms inward and forward, leading to that compression again. Although every "ergonomic" chair comes with armrests, I am absolutely convinced they are the devil, and I will never work on a chair with armrests again.

Finally, your wrists. They should be straight but relaxed, with your palms angled a bit inward and toward each other, and your fingers gently curled. Ok, all that feels great, but where does the computer come in?

Working at a Computer
The key is to position your computer so that you deviate from this comfortable seated position as little as possible. That means you want your keyboard as close to your lap as possible. This requires a very adjustable keyboard tray or a very very low desk with a thin surface--all nearly impossible to come by. Ideally, the keyboard should be level, or even tilted slightly away from you. (Almost all keyboards insist on tilting toward you, but that's no good if you want to sit comfortably with your hands near your lap.) Keyboards that angle your palms slightly inward, instead of keeping them flat and pointed forward, are probably a good thing. If you're right-handed like me, I think the most important thing is to have a keyboard that lets you move the mouse without reaching over a numeric keypad. You can find good inexpensive keyboards without numeric keypads. Finally, you want to position the monitor so that you can look at it at a very slightly downward angle, without moving your head forward. That probably means raising your monitor by putting it on top of books or boxes.

Finally, you don't want to sit like this for long periods of time, no matter how comfortable your seated posture is. Take frequent breaks and stretch often. (I'm bad at remembering to do this.) For me, the most effective stretches have been the ones where I stretch my arms out to the sides with my palms forward, stretching them backward. You can also achieve this sort of stretch by holding your arms against a wall, or by lying on your back with your arms hanging over the sides of a couch/bed.

Getting Better
Perhaps most importantly, sitting properly requires the sort of strength you get from a good night's sleep. Massage and stretching can help your body begin its healing process, but deep sleep is when the real healing takes place. Getting a good night's sleep with regularity is critical. Drinking enough water is probably also a good thing, since this may help your body as it removes those metabolic wastes. And finally, you won't get better from RSI overnight. It took years to do the damage, it will certainly require many frustrating months to undo it.

Is all this working for me? Am I getting better? I sure hope so...