My recommendations for RSI treatment

I’ve written this guide because I’ve noticed up that a very large number of people I know (especially effective altruists) have had some trouble with repetitive strain injuries (RSI), which is when overuse or repetitive motions lead to pain in one’s muscles, nerves and tendons. Some other people in the effective altruist community suggested that I write it for this reason. This guide is mostly about RSI in the hands or arms caused by computer use, but people with other types of RSI or other types of chronic pain may find some parts useful.

This guide is meant as an adjunct to a treatment program involving medical professionals. I’d recommend going with their recommendations anywhere it conflicts with the recommendations in this guide (which is hopefully not too often).

There is a pretty long list of professionals that you can see about RSI. These include specialist doctors such as sports medicine doctors, rheumatologists, orthopedists, physiatrists, and pain specialists. It also includes physiotherapists, massage therapists, occupational therapists, and ergonomic specialists.

I’ve done some research into the science behind treating RSI, but I don’t have the kind of background knowledge of a medical professional. The evidence on this topic is not great, so some of the claims in this article are based on anecdotes.

I try to focus on where I think I can be the most helpful. I have lived with RSI for a few years, which I think gives me some insight that medical professionals may not have. I’ve also noticed that at least in my interactions with them, medical professionals do not give many suggestions on daily living with RSI. I could not find another guide if this kind that overviewed the all relevant considerations for living with RSI in an evidence-based way.

I use the term RSI in this guide as an umbrella term to describe multiple conditions including tendinitis and carpal tunnel syndrome. I think this vagueness is a virtue in this case because it seems like generally similar considerations apply to all of these conditions. I use the more specific terms as appropriate. There are some tests that you can get done to diagnose carpal tunnel syndrome and this is likely worth doing for any prolonged case of RSI.

I recommend a number of products and websites in this guide. I haven’t received sponsorship from any of the sources in my recommendations are only based on the merit of those products and websites.

Surgery is seldom a good option for RSI, so try to get a second opinion before going ahead with it if an orthopedic surgeon does recommend it. Steroid injections are also hazardous and unreliable, so be careful before proceeding with them.

My case:

I’ll share my story of RSI here. It may help you know where I’m coming from and may give you some insight into your case. I have not recovered from RSI, though my RSI and associated chronic pain has improved a great deal, and there is some hope for a complete recovery in the future. I’ve also learned to get around the limitations my RSI gives me, and it no longer defines me or gives me serious problems.

I’ve had RSI for approximately the last four years. Prior to developing it I had also began to feel a number of other bodily pains such as neck and back pain. I attribute this to a student lifestyle, a ‘no pain, no gain’ attitude, weekend warriorism, workaholism, perfectionism, anxiety, and a stark lack of physical health problems in the past leading me to tacitly assume that my body was invincible.

I think that probably these foreshadowing physical health problems set the foundations for me to develop RSI. I’ve tried many different things but I definitely didn’t find any ‘silver bullets.’ I’m now able to use my hands to do almost any normal task except computer use (which I can only do small amounts of). I’m now good enough at using text-to-speech software that I’m able to use a computer at approximately the same speed for almost any task as I could before the injury. The chief remaining problem is some chronic muscle pain that I’m now focusing on and trying to make progress on.

What to do when you start to notice you have RSI?

When you notice pain associated with RSI for the first time, the best approach is probably to stop the triggering activity until the pain goes away. This may mean changing the tasks you’re working on for a few days, but if this is an option available to you, this rest period may pay off richly in the future.

You may also want to make some changes to your work set up when you go back to work. For example, if you normally work from a laptop you could buy an ergonomic keyboard and mouse and switch to a desktop set up for your computer. Too much of the same type of movements, especially if they are awkward movements, lead to the development of RSI and just changing seemingly minor things may make a big difference.

There also some setups that are in general more ergonomic and so should be helpful for the RSI. These setups put your body a more natural, less awkward, less contracted, and easier positions for your body. But remember that your body also just likes variation. I personally fell into the trap of trying to attain ‘the perfect ergonomic posture’ at the expense of variation and this was a mistake. You can try periodically switching between your ergonomic equipment in order to achieve this.

At this stage of the RSI that is probably good to pay close attention to the pain and not try to push through it. If the pain is getting worse and worse, definitely do not try to push through it. If the pain doesn’t go away after this rest period or comes back, I’d recommend going to a physiotherapist and possibly other healthcare professionals. You might also try experimenting more with your computer setup. For example, you might try standing while working for part of the day.

If you can afford to, it can make sense to throw more money and time into treating the RSI then might naïvely seem appropriate. RSI is something that can seriously cut into your future productivity and well-being, so this can easily be worth it.

RSI is counterintuitive:

One feature of RSI that I found to be counterintuitive is how it can involve much more of the rest of your body than you would expect. I guess this is because “everything in the body is connected” and if one thing starts to go wrong it can have a ripple effect on the rest of your body. I don’t think this is specific to RSI, but is general feature of the sorts of injuries that physiotherapists and massage therapists treat.

For this reason, don’t be surprised if a physiotherapist recommends that you focus on your neck or another seemingly unrelated part of your body, even if pain in that area that is far from the chief complaint.

Also for this reason, it is also possible for the RSI to spread or lead to other conditions. This may happen because whatever contributing factors that contributed to you developing RSI in the first case are still present and may contribute to the second case. For example, if you develop RSI from using a mouse with your right hand and switch to using it with your left to avoid the RSI, you might then develop RSI in your left hand! It may also spread or lead to other conditions because systems in the body are connected with each other in surprisingly intimate ways. For example, if you hurt your foot this could affect your walking posture which could affect your leg and so on. See the section on trigger points for further information about this.

What to do if you have recurrent or chronic RSI

At some point RSI may develop into a second phase and different treatment considerations apply at this stage. At this point the ‘completely abstain from all triggering activities’ treatment route may no longer make as much sense. If you can easily abstain from triggering activities, such as by speech to text software instead of a keyboard and mouse, this approach may still make sense, but avoiding triggering activities is now less pressing. This transition from acute to chronic injury may take place because the original injury heals but is replaced by trigger points or simply a pain condition.

At this stage it seems like people may begin to recognize that they can regularly engage in a certain amount of triggering activities, for example using a keyboard for three hours a day, without their RSI symptoms becoming progressively worse or unmanageable.

I don’t have a good scientific or mechanical understanding of why this second phase of RSI exists. One explanation that I’ve heard, which may not be entirely correct but may at least give you the right general idea, is that at this point the condition may become primarily related to trigger points in the muscles rather than tendon degeneration or nerve damage.

When my RSI reach this stage, I found that certain psychological techniques were especially helpful. I described these more in the psychology section, but in general adopting a mindset of ‘accepting your pain’ and seeing that it is no longer a reliable signal that ‘your body is damaged’ or that ‘you are broken’ was very helpful.

At this point it’s worth trying a lot of different healthcare practitioners including specialist doctors. If your RSI is not getting better, I would recommend to continue to experiment. A lot of people just haven’t tried enough treatment options. It is good to adopt the mindset of trying any plausible treatment as long as the costs and risks from the treatment are low.

Text-to-speech software:

Using text-to-speech software to replace your keyboard and potentially mouse usage represents the most decisive option in avoiding triggering activities, though also the one that that has the largest time cost as a trade-off. Even if you decide not to go with this option, it may give you some peace of mind to recognize that this can be a fallback option if your RSI ever gets too bad.

You might say that there are two main levels to using voice to control your computer. One is using Dragon to replace longer stints of natural language typing including writing emails and writing in text documents. You can do this to reduce your keyboard usage without eliminating it entirely while still using a mouse. This probably won’t slow you down and might even speed you up a little bit, all things considered.

The next level is to use voice to control all (or essentially all) of tasks on your computer. At this point you are no longer only doing speech to text but giving many voice commands to your computer. This is what I do now, and it works adequately, though Dragon is not well-suited to this and the learning curve is steep. It’s also hard to get Dragon to recognize long strings of characters that are not from a natural language, so programming will be especially difficult. I know that some people are able to do this, however.

There are some people who even prefer using voice to control the computer of our other options even if they do not have any problems with RSI. I have a bit of a hard time understanding this, but if you are particularly a computer ‘power user’ this could be true for you.

My current set up for controlling my computer by voice is the latest version of Dragon NaturallySpeaking, an add-on to Dragon NaturallySpeaking called Voice Computer, and a $120 microphone. The main functionality of Voice Computer is that populates each window or tab of your computer with a series of numbers at almost every clickable locations (intags). Now to to click next to one of the numbers you just need to speak the name of the number and Voice Computer will click that location for you.

If you buy Dragon NaturallySpeaking, I would highly recommend buying it from the website Knowbrainer.com. They will give you much better tech support then you can get from Nuance (the company that makes Dragon). The Knowbrainer website also has its own software that is an add-on for Dragon that is actually free to people with a disability or RSI (you just have to email them with any sort of evidence of the condition). I just prefer Voice Computer because of its numbering system, but in other respects Knowbrainer appears to have better functionality.

Their website and forums also contain a lot of useful information. At least if you are relying entirely on speech to text software to control your computer, it can be very frustrating. I’ve gotten a fair bit better at using the software over time, but Dragon and add-ons to Dragon are often very buggy and you may find yourself having to invest very significant amounts of time into learning to use them better and troubleshooting.

As an example of some of the problems you may run into, you may run into serious problems if you try to use Dragon NaturallySpeaking on a computer with less than an I7 processor and 8+ gigabytes of RAM.

Unfortunately, the version of Dragon that was compatible with the Apple operating system has now been discontinued and there don’t seem to be any competitive alternatives.

Trigger points and self-massage:

Trigger points are hyper irritable spots of muscle that, if some sources such as painscience.com are to be believed, may be responsible for most cases of RSI and many other muscle pain issues. They are also more commonly known as muscle knots. There different theories of what trigger points are, and I believe a precise mechanism has not been pinned down, but my impression is that the science saying that that there is something generally similar to trigger points going on, is quite strong.

Most of the information that I get in this section comes from painscience.com. The guy behind that website, Paul Ingraham, is a scholarly and sceptical former massage therapist and now full-time researcher for the website. His methodology seems to be good, though one thing that gives me pause is if trigger points are as big of a deal as he says they are, I would expect more health professionals to be talking about them and talking about them more prominently. I only outline some of the most relevant information in this section, and I would encourage you to check out the pain science website for better information on this topic.

This article gives some good tips for how to treat trigger points. He also provides a trigger point symptom checker in that article to try and diagnose if you have trigger points. The best treatment is probably some combination of self-massage as well as visits to a professional massage therapist. The balance between these two methods of treatment depends on how much money you can afford to put into the treatment, but you probably want to have a little bit of each one.

If you rely only on professional massage, you probably won’t be able to afford the kind of frequency of treatment that is best for trigger points. If you rely only on self-massage, you will probably miss some trigger points that may be important and neglect certain techniques that may be useful.

If you mention you do self-massage to them and are interested in hearing tips, a good massage therapist should give you some advice on where to focus on and give you feedback on your methods. A good massage therapist should also listen when you tell them that you feel a trigger point in an area that they are massaging, and focus on that spot. It’s probably best to try to find a massage therapist who specializes in trigger points or RSI. Normal massage techniques will also help with trigger points, but it’s better if they know what they are doing in treating trigger points.

There are ways of adequately massaging your whole body yourself without over stressing your arms in the process. Doing so takes a few tools and takes a while to learn how to do well, but is not difficult to learn how to do adequately.

The basics of trigger point self-massage is to put pressure on your muscles and try to find spots of muscle that are particularly painful to the touch. The spots will probably give you give you a ‘pleasurable feeling of pain’ rather than an aversive one. The pain may be intense, but should feel somehow ‘right’ or relieving. You may also notice that when you touch the spot it refers pain to another place on your body. This pain may also somewhat duplicate your symptoms, which is a very promising sign.

Another promising sign is if you notice your muscles involuntarily twitch during the massage. You may notice that the trigger point feels like a small ball in your muscle, perhaps the size of a pea. The muscle that has the trigger point and it is likely to feel very tight, it may feel more hard than you would think a muscle could be. Though trigger points are not necessarily associated with tightness. The basic technique is to apply pressure to the trigger point to keep it at a certain level of pain, and as you experience less and less pain from the same amount of pressure, increase the pressure to maintain the same level of pain.

Hopefully you will achieve a release of the trigger point which may be accompanied by more involuntary muscle twitches. After this the trigger point may still hurt, but it may be more like a soreness in the area then an exquisite tenderness. At this point some sources recommend stretching the area or performing mobilizations involving the area. Even if you do not succeed in releasing the trigger point in one session, the massage will likely be helpful in reducing your pain and releasing the trigger point in the future.

This is the basic technique, though you may want to add some variation to this. I find using my intuition and doing whatever massage techniques feel good to be helpful here. The idea with trigger point massage is to use the massage to relax parts of muscle that will not relax on their own. It is therefore very helpful to try and relax the muscles you are massaging and any nearby muscles while doing the massage. Try to prioritize self massage techniques and possessions that allow you to do this. Breathing deeply is also helpful with this and is highly recommended. One of the main reasons you want to avoid excessive pain during the massage is that excessive pain will lead you to tighten your muscles, which is the opposite of what you want. You can also experiment with doing self massage during or after a hot bath or shower. Or combine it with contrast therapy.

After a trigger point is released it will likely come back at some point. For this reason it is important to be diligent and continuing to massage the spot. Do this perhaps 1 to 6 times per day. Regularity is more important than duration when it comes to this.

One thing you may notice is that when you release certain trigger points, it may afterwards be more easy to release other trigger points. Trigger points may cause each other to come back. Indeed, you may not be able to get rid of certain trigger points without releasing other trigger points first. You may suddenly find that you are able to make a lot of progress with treating trigger points after finding some but you didn’t know about that were causing other trigger points.

In general, trigger points in your neck and other core areas of your body are more likely to cause other trigger points then trigger point in your extremities. So if you have trigger points in core areas of your body that seem important, then it can be good to focus on these.

You can find webpages and books that give you more information about where trigger points for most commonly, their common referral patterns, and specific problems that trigger points in specific areas tend to cause. The best of these may be the Trigger Point Therapy Workbook by Clair Davies. However, at least initially you’re probably better off just knowing the basic principles of trigger point treatment and ‘chasing the pain’ by doing trigger point massage in the way that feels best to you.

The tools that I would most recommend for this are a spiked foam roller, a lacrosse ball, and some sort of hand tool that lets you exert more pressure with less force. A body back stick is also helpful. You should be able to hit every spot on your body with the right angle and a lacrosse ball or spiked foam roller between you and a wall. Using a tool to massage your neck is not recommended, at least before you become skilled at self-massage. This is because there are important blood vessels and fragile structures there. The back of the head is another region to be careful in. Books like The Trigger Point Therapy Workbook have instructions on how to massage these regions safely.

If the pain does really seem to be localized in your hands and arms, you can get quite far with just rubbing your arms against objects such as chair armrests and exerting pressure. Massage oil can also be helpful here. There’s a device called an Armaid that specifically made for massaging arms and hands that is pretty good. It’s relatively pricey, but like many of these devices, they can easily be worth it for the right person.

Physiotherapy and exercise:

Physiotherapists are some of the healthcare professionals with the most relevant area of practice to RSI. Unfortunately, like massage therapists they are not as well educated as doctors and also often believe in some ‘woo.’ The recommendation I’ve heard is to try and avoid having them using machines such as ultrasound on you, because these often have weaker evidence basis. My understanding is that exercising the injured part is basically always recommended for injuries such as RSI. The physiotherapist should give you a progressive exercise routine that works with your current level of strength and injury.

There are a variety of different exercises that you can do to increase strength in the region and some of them hurt in a problematic way you can switch to others that do not. Exercising the hurt area helps to repair it, prevent atrophy, and correct muscle imbalances.

Mobilizations and stretching:

Mobilizations, defined as taking a joint through its range of motion, may be very helpful for improving RSI. I’m unsure of the mechanism, but the musculoskeletal system seems to operate on a ‘use it or lose it’ basis and mobilizations may increase mobility, stop the formation of new trigger points, and speed recovery.

Mobilizations may could be particularly helpful if done regularly as part of a break from a triggering activity. For example, you might set a timer to take a break from using the keyboard and do circles with your wrist and fingers.

The evidence behind usefulness of static stretching (as distinct from mobilizations) is less clear. Painscience.com and other sources I rely on suggests that the evidence adjusts that static stretching does not have a useful effect besides increasing flexibility and that increasing flexibility is often not useful.

On the other hand, even if the evidence might be lacking, there still seems to me to be a consensus among healthcare professionals that stretching is useful, and so I still do it. Also, it is possibly the case that even if flexibility isn’t always useful, RSI may be associated with pathological decreases in flexibility and self-stretching may be useful in this specific case. The general rule behind stretching is that it shouldn’t cause you any pain.

The psychology of RSI

Your psychological response to RSI may be quite relevant. Getting RSI may be quite a blow to you, especially if you have a more workaholic bent. When I got RSI I struggled with thoughts like ‘my body is falling apart’ and ‘my working life is over.’ It’s important to be able to be okay with taking some time off to recover.

It’s important to try and stay positive and not catastrophize. If you form strong negative associations with the pain, this may make the pain substantially more aversive than it would otherwise be. There are online support groups available if you need them. Stress may also worsen the pain that you feel and lead to a negative spiral. It is important to remember that pain is not always a reliable signal of body damage, especially in cases of chronic RSI. Your interpretation of something as being threatening may increase the amount of pain that thing causes you.

You may want to try some guided meditations for dealing with chronic pain. Seeing counsellors is also an option if the psychological aspect of RSI seems to be particularly important for you. Normal mindfulness meditation may also be helpful for coping with the RSI as well as potentially reducing the pain itself. If you feel distracting pain during the meditation you can focus your nonjudgmental awareness on the pain and this should make it feel less aversive, at least at the time.

Avoiding triggering activities:

One key way of recovering from RSI is by avoiding doing movements or activities that aggravate the RSI. It may be surprising how simple or specific triggering movements for RSI may be. For example, throughout most of the time that I have had RSI, I have been able to do most normal exercises at the gym. So I was able to maintain my grip on substantial weight with my forearms without much trouble while using a normal mouse could bring on pain within a few minutes.

I haven’t been to many appointments with occupational therapists, but it’s my understanding that they are the experts with the most relevant expertise to deal with this question.

One thing to keep in mind when avoiding triggering activities is to only avoid the specific movements that exacerbate the RSI and not avoid activity altogether. Avoiding activity altogether may lead to atrophy, inflexibility, and immobility which can exacerbate the RSI.

For this reason, it is not a good idea to wear arm braces for very long stretches of time. These braces also keep your arms relatively immobile which can cause trigger points. Probably the best time to wear arm braces (if at all) is is during the triggering activity itself.

Doing activities with your arms that engage them in light exercise and does not exacerbate your RSI will probably be helpful for the RSI. If you do need to start avoiding many activities it might be good to substitute others such as using a rowing machine at the gym. I haven’t tried much of it myself, but if you prefer to get your exercise through a hobby, climbing or bouldering seem like a great way to exercise your arms and hands (if done in moderation).

Another key thing to remember while avoiding triggering activities is to avoid substituting for activities that can become new triggering activities. Once you already have RSI, it can be more easy to develop RSI associated with new movements. For example, I started to use a foot mouse after I developed RSI, but I fairly quickly developed knee pain associated with using the foot mouse.

I think the key thing to keep in mind when substituting activities is to keep everything in moderation and don’t continue the activity if it starts to cause you much pain. If you live with other people and certain household chores such as cleaning up after yourself hurt your arms, consider asking if you can do more of the tasks that do not aggravate your RSI instead of the tasks that do aggravate your RSI. Your housemates or partner should be understanding about this. If many different household chores aggravate your RSI you could consider paying for a cleaner or other person to do these tasks.

Ergonomic devices:

Ergonomic devices are very useful for recovering from RSI while still being productive. There is a wide range of ergonomic devices and which ones work best for you will depend on which specific movements are triggering your RSI.

Unfortunately, it often seems to be the case that once the label “ergonomic” is placed on a device the price of that device magically doubles or triples. One way to get around this problem is to see if your employer or healthcare system is willing to buy you these devices for you. There may also be private charities in your area that may be willing to buy these devices for you.

Having said that, even with a hefty price tag these devices can easily be worth it even if you have to buy them yourself.

Tips and tricks for avoiding triggering activities:

• If touchscreens start to aggravate your RSI, it is possible to use your phone in some new ways. I am only familiar with android phones so this part will only concern android phones, but I imagine that there are similar solutions for other phones.
• There is an option to type using your voice on a standard android keyboard. You may be able to replace a reasonable amount of typing who on your phone through this option.
• It is possible to use a touchscreen with your nose. I was very reluctant to do this at first because it just looks really weird, but hey, it works. This method is more awkward than using your fingers, and you can’t easily replace all of your touchscreen usage with this method. Be careful that you don’t overuse this method, since you may stress some muscles in your neck. Despite how weird you might think this method as, I’ve never had a single person comment when I’ve done this in public.
• Using a voice assistant on your phone can allow you to reduce touchscreen usage. For example, you can say “okay Google, search for XYZ.”
• There is a voice access setting on android that places numbers in clickable areas on your android screen and allows you to to issue additional commands such as “scroll up.”
• You can easily buy electric versions of many household items if the associated action begins to trigger your RSI. For example, I found electric toothbrushes and electric can openers helpful.

Resources:

Most useful resources I’ve tried:

· A vertical mouse

· A pen mouse

· Dragon NaturallySpeaking

· Voice Computer

· A ‘joystick mouse’

· Kinesis Advantage Keyboard

· Kinesis Freestyle Split Keyboard

· A trackpad mouse

· Topical pain relief creams such as those containing menthol and methyl sallicylate

Other resources that seem like they might be good but I haven’t tried:

· Smartnav

· Eye movement tracking software

· Mouse foot pedal

· Foldable laptop stand

Bibliography:

Unless otherwise noted, all sources are from painscience.com or from experience.

Many thanks to John Maxwell and Louisa Rodriguez for feedback and suggestions on this post. Many thanks also to (again) John Maxwell and William Saunders for giving me advice about managing my RSI, some of which has been incorporated into this guide.