What Causes Repetitive Strain Injuries?

Repetitive strain injuries (RSI's) are a blanket term covering problems like carpal tunnel syndrome, tendonitis and "dorsal wrist syndrome." These problems affect millions of Americans today, but the cure, as always, depends on the cause. If you're experiencing symptoms of carpal tunnel syndrome, it may help to understand what's actually going on beneath your skin.

According to most recent studies, the damage caused by repetitive strain injuries results from structural changes in the muscle fibers as well as decreased blood flow in the affected areas. Nerves can also be involved (as in Carpal Tunnel Syndrome) but nerve compression is not the first problem that occurs. If you're experiencing nerve pain it's because something – usually damaged tissue and inflammation – is pressing down on the nerve, which is what causes the numbness, tingling and loss of mobility that goes along with carpal tunnel syndrome and other RSIs.

But don't take my word for it. If you're experiencing wrist pain, I recommend you do some homework to get a better understanding of what's really causing your pain. It might not be carpal tunnel!

A good place to start is this study on "Overuse Syndrome." A group of scientists took biopsies from the hand muscles of injured and normal subjects, which allowed them to study the structural damage in the muscle fibers and see how it lined up with the severity of the person's symptoms. In another study, biopsies were taken from neck muscles, which revealed that reduced local blood flow was found in the injured areas. In short, the greater the pain, the greater the reduction in blood flow.

So how should you deal with your wrist pain? One way may be to increase your circulation. Here's a pretty good article on how to increase circulation to your arms. Apparently, in this sedentary world of ours, we need to work a little harder to keep our blood moving.

Oh, and if you are using your trackpad to click on any of these links, STOP RIGHT NOW! Read my posts on the ergonomic carpal tunnel mouse and the joys of voice recognition software. I'm using it right now.

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The Best Ergonomic Keyboards and Accessories

How should you treat your carpal tunnel syndrom? 

If you have carpal tunnel syndrome, repetitive stress injury or tendinitis, or if you're trying to avoid it before it starts, the best thing you can do is get yourself an ergonomic workstation. I've been struggling with tendinitis for several years now, and every doctor I've spoken to has said that the best treatment is ergonomics. They even recommended ergonomics over rest, saying that the most important thing is to keep you arms in the correct posture to avoid further wrist strain.

If you can avoid typing, I would still recommend it. But when you do work, make sure you have the best products out there. Here are some of the things that worked for me:

Step number one: Get yourself some excellent voice recognition software.

Voice recognition software types as you speak. This will take a huge part of the burden off of your hands. Keep in mind, however, that you won't be able to use it for everything. Things like proper nouns (names, addresses, etc.) will be hard for it to recognize, as will some numerical data. So even if you have great software, you'll want an ergonomic keyboard and mouse to back it up. Also, I'd suggest spending at least $30 on a good microphone. 

Best voice-recognition software:

... for Mac users: MacSpeech

... for PC users: Dragon NaturallySpeaking

These two programs are essentially the same, since Mac ended up buying the Dragon NaturallySpeaking software. Basically it was the best thing out there, and still is. Don't bother with any other voice recognition program. These are the only ones that really work.

Best ergonomic mouse: Evoluent Ergonomic Vertical Mouse 3

As someone whose problems began from using a mouse rather than typing, I can say with authority that a good mouse is crucial to reducing carpel tunnel and wrist pain. The Evoluent mouse is also referred to as "the handshake mouse," because it allows your wrist to

 remain in the natural, handshake position, as illustrated below. The twisting of the wrist bones when you use a regular mouse puts extra strain on every muscle and ligament in your wrist, and is likely to be the primary cause of repetitive strain injuries associated with typing.

Best ergonomic keyboard: Microsoft Natural Ergonomic Desktop 7000 

This is what I use, and it's by far the most popular ergonomic keyboard out there. It works on a similar principle as the mouse, allowing your wrists to maintain their natural, un- twisted position. It's also called a split keyboard, because it's split in the middle with each side sloping downwards. Once I started using this I was able to type at least five times as much without pain. It's a very, very worth it. Read more about it here.

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Standing Desk May Alleviate Carpal Tunnel Symptoms

Bad posture is the number one cause of carpal tunnel syndrome, wrist pain, back pain and neck pain.  And if you think you can have good posture by simply sitting up strait, think again. According to recent studies, sitting in any chair for long periods of time is unnatural and unhealthy, no matter how good your chair OR your posture. So what should you do about it?

Until we all have computers installed in our sunglasses, it looks like the standing desk is the best option.  Standing while working is good for your whole body, not just your wrists, and it may help you correct the poor posture habits that are causing your wrist pain. Lifehacker has some great articles about the benefits of a standing desk, and where to buy (or build) one of your own. There's also a good how-to guide to the standing desk on wired.

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The Many Causes of Wrist Pain: Subscapularis Muscle

If you're experiencing carpal tunnel symptoms, the problem might not just be in your wrists. After three years of struggling with chronic, non-carpal tunnel wrist pain and elbow pain, I went to see a massage therapist who specialized in deep tissue massage, also known as rolfing. (Just a warning: this massage technique is not for the faint of heart). The therapist worked first on my wrists and elbows, especially the spot above my elbow. This hurt quite a bit, but it was nothing compared to the pain I felt when he massaged my armpits. Well, not my armpits exactly: my subscapularis muscle, which is responsible for rotating the shoulder slightly when the arm is lifted. Sound familiar? Unless your typing position is perfect in every way, this muscle will be flexing constantly to hold your arm in place. And my subscapularis, as it turned out, was tighter than a violin string. 

I had never felt pain in this muscle before, but once the massage was over I felt huge relief from my wrist pain and elbow pain. Afterwards I read this article on Massage Today, which lists the symptoms caused by an overly tight subscapularis muscle. The symptoms? Wrist pain. More specifically, referred pain (pain in an area that isn't the source of the problem) in the back of your shoulder, the underside of your arm, and wrist pain. Just follow the little red dots the picture below. If these are your symptoms, the subscapularis might be a cause.

Referred Wrist Pain from Trigger Points in the  Subscapularis

So, how do you self-massage your subscapularis muscle? Take a tip from the sky, and get yourself a foam roller. Your wrists may thank you.

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The Dangers of Painkillers for Carpal Tunnel and RSI

If you have to take a pill to counteract another pill, why not just cut them out altogether?

Are wondering how to treat carpal tunnel symptoms? If so, take my advice and don't use painkillers. When I first went to a doctor complaining of wrist pain, she immediately offered me Vicodin. I declined, opting instead to take her suggested daily dose of Ibuprofin. What she didn't tell me was that continuing to take this drug for over a month could give me ulcers and stomach bleeding, and sure enough, one month later I was doubled over in pain after every meal. When I told her this during a follow up visit, she recommended another pill to protect my stomach lining. This seemed pretty counter-intuitive to me. If you have to take a pill to counteract another pill, why not just cut them out altogether? The Ibuprofin wasn't working anyway. I got more pain relief from heating pads and tiger balm. So I stopped taking pain killers, and within a couple months my stomach was back to normal. My wrist pain, unfortunately, was still the same.

If you read the news with any regularity, you've probably already heard about the FDA's recommended ban on the popular prescription painkillers Percocet and Vicodin, because of their effects on the liver. The offending ingredient in both drugs is acetaminophen, aka Tylenol. Although relatively safe at the recommended dose, so many products contain acetaminophen that patients are likely to overdose without realizing it. If you take vicodin in the morning and later use cough syrup, Excedrin or NyQuil, you just overdosed.

The ban will probably not happen any time soon, but the fact that it was suggested is pretty worrying. Unless your carpal tunnel pain is absolutely unbearable, my advice is to beware of drugs. They usually don't help people with chronic wrist pain in the long run, and they may only mask the source of the problem.

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Swedish massage instructions for hand and wrist pain

The blog of herbs and health has a great post on how to give someone (or yourself!) a forearm massage. Releasing muscle tension is key to curing almost any kind of chronic wrist pain, so I recommend you learn how it's done. If you can't afford a private massage, search for massage schools in your local area. They usually offer discounted student massages which can be just as good as the professional variety.







For further self-massage instruction, check out this video:

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Heal Carpal Tunnel Syndrome with Ergonomics

Do you type on a laptop? Well, don't. Laptop keyboards are typically small and flat, which forces you to arch your hands and put undue strain on your wrists. Looking down at the screen also puts a strain on your neck, which can lead to compression of the carpal tunnel.

If you have wrist pain or want to avoid getting it, make sure your work station corresponds to basic ergonomic guidelines. That means that your forearms are parallel to the floor when you type, your back is strait, and your chin is up, like so:



If your desk is too high you will arch your wrists, which is also no good. This is the mistake most people make at work, since desks are at a comfortable height for writing, but not typing.



So what should you do if you use a lap top? Get a second keyboard! I recommend the
Microsoft Natural Ergonomic Desktop 7000.



This is what I use, and it's by far the most popular ergonomic keyboard out there. It's called a split keyboard, because it's split in the middle with each side sloping downwards. This takes a little getting used to, but in the end it's a much more natural position for your wrists. Once I started using it I was able to type at least five times as much without pain. It's very, very worth it. Read more about it here.

You can also buy a fancy computer stand to elevate your laptop so that the screen is directly at eye level. Or you can use a good old fashioned stack of phone books, which are free. Keep it ergo, keep it safe.

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Wrist pain and TMS

If you'd like to hear more about the treatments described in the previous post, there are a number of good sites out there devoted to John Sarno's theories about Tension Myositis Syndrome. Here are just a few of my favorites:

tms wiki
tmsrecovery.com
tarpityoga
Rachel's RSI homage
Dr. Sarno's website

In the meantime, keep in mind that a large part of the treatment he recommends lies in truly believing that you are fundamentally o.k. - and that there is nothing "structurally" or physically wrong with you. If you feel pain, try not to focus on it. Think instead of the emotional anger or frustration that may be contributing to it, and try to own that frustration. It may be a stretch for some, but a lot of people with carpal tunnel syndrome or other RSI's have experienced partial or complete relief by doing this. Rachel's RSI homage has some great testimonials.

There's also a fair amount of independent evidence that the brain can in fact be trained to increase or decrease the amount of pain you experience. This study by Sean Mackey, a Stanford University pain expert, used MRI brain scans to show that focusing on pain increased it, whereas focusing the attention elsewhere could decrease or even eliminate the sensation of pain.

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Carpal Tunnel Syndrome and Dr. John Sarno's Mindbody Medicine

Whether you have Carpal Tunnel Syndrome, tendonitis or repetitive strain injury, there are a million people out there who will give you advice about how to deal with your pain. But before you continue to treat your wrist pain, I highly recommend you check out Dr. John Sarno's book The Divided Mind: The Epidemic of Mindbody Disorders. Dr. Sarno argues that many of the conditions often associated with fibromyalgia, carpal tunnel syndrome or back pain are actually caused by various forms of emotional repression. I know it may sound Freudian at first, but there's a lot of evidence to back up his claims. Here's his theory.

Scientists and doctors are starting to come around to the fact that the mind and body are not separate entities but part of the same system. And when you think about it, this mind/body connection makes a lot of sense. If your brain can process cues from your body - registering pain, fatigue, and temperature changes - why can't your body be affected by your mind? For example, you've probably noticed that your muscles tense up when you're feeling nervous. When you're embarrassed, you might blush. Both of these situations are widely accepted examples of purely emotional reactions being displayed as physical (bodily) phenomena.

Dr. Sarno spent years treating patients with chronic back pain. After a while he began to notice common personality types among his patients. Many of them were perfectionists and chronic do-gooders. They tried hard to please others, and when they failed they often blamed themselves harshly. To make a long story short, Sarno hypothesized that many of these people were repressing feelings of anger and frustration that were harmful to their good self-image. When he made them aware of these feelings, many of his patients experienced immediate relief from their painful symptoms.

This does not mean that their symptoms were imaginary. In all of his writings, Sarno adamantly makes a distinction between real physical pain which is caused by emotions, and "psychosomatic" pain that is merely imagined, or "all in your head." Studies of most of the patients he diagnosed with this condition, which he called "Tension Myositis Syndrome" or TMS, showed one common physical characteristic: decreased blood flow to the areas where they experienced pain. His theory is that this decrease was the mind's attempt to distract the patient from emotions that they did not want to recognize. He also noticed that the decrease occurred in areas of the body where the patient might reasonably expect to feel pain, generally in an area there had been a lot of buzz about in the media. For a long time it was back pain. Then, when Carpal Tunnel Syndrome became a widespread source of attention, more and more people started showing up with pain in their wrists. Coincidence?

Again, this does not mean that these people's pain was "all in their heads." It was very, very real, and was caused by decreased blood flow to their wrists. Other independent studies have shown that decreased blood flow can cause both pain and temporary structural damage to muscle fibers. This study on "Overuse Syndrome," which was cited in the Google blog's entry on carpal tunnel syndrome, is one such example. In keeping with this, Sarno noticed that most of his patients found relief from treatments that increased circulation, such as heat and massage, and none had lasting structural damage once the source of their problem was addressed.

Now I'm not a sucker for self-help books, but I really think there may be some truth to this. What finally sold me was that a group of high achieving Harvard students managed to heal their carpal tunnel syndrome just by following the suggestions in his book. They started a website to document this amazing event, called Harvard RSI Action. It's very worth a read.

I'll be posting more on this later, but for now I highly suggest you keep an open mind to these theories, especially if you've experienced other symptoms associated with TMS, such as back pain, leg pain or stomach problems. Here's an interview with Sarno, just to give you a quick idea of where he's coming from.

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Carpal Tunnel Syndrome and Neck Pain

One of my biggest problems with the standard medical treatments for Carpal Tunnel Syndrome is that, like most western remedies, they treat the symptoms rather than the cause. Let's say you're having pain in your wrists. You go to the doctor and they suggest that your problem is compression of the Median Nerve, the primary "cause" of CTS. But your median nerve doesn't just appear in your wrist and disappear when it hits your elbow. No, it travels all the way past your elbow, up to your shoulders, your neck and (surprise!) your SPINE.

Everyone knows that poor sitting posture contributes CTS, but doctors - especially wrist and hand specialists - rarely ask you how your back and neck is feeling when you tell them your wrists hurt. This is a big mistake on their part. Throwing ibuprofen at the problem won't help you if the muscle tension and poor posture that are causing your pain continue to go untreated.

There's a great post on this issue at Dr. Davis' Back and Neck Blog, which recommends seeing someone with chiropractic experience in the upper spinal regions. My recommendation? Stretch your neck! I'm no doctor, but I know from experience that this can help immensely.

My Favorite Neck Stretches for Wrist Pain

Performing regular neck stretches has been a lifesaver for me. Here is my #1 all time favorite carpal tunnel relieving exercise, which I can reel working all the way down to my fingertips. I highly recommend it.

1. Hold your right arm behind your back, pulling down gently with your left hand. Tilt your head to the left from the crown up, keeping your face and gaze forward, until you feel a stretch in the side of your neck. Hold for 30 seconds.







2. Hold your right arm behind your back, pulling down gently with your left hand.This time, turn your head and face sideways, so that you are looking off to your left. Hold for 30 seconds, switch arms, repeat.

3. Below is another favorite stretch of mine, which is pretty much self explanatory. I especially like the second triceps stretch, since for me the pain often travels all the way up my arms.

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Alleviate wrist pain with Voice Recognition Software

There are a lot of voice recognition programs out there, but Dragon NaturallySpeaking 10 is by far the best. The Mac version is MacSpeech Dictate, and is basically the same program. It's good too, in fact I'm using it right now! Don't bother with any older or cheeper programs - they don't work. If you want to type without using your hands, get one of these two programs and a decent microphone, and you'll be good to go.


Read reviews of these programs here.

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Self-Test for Carpal Tunnel Syndrome

Before you begin to treat the pain in your wrists, you should know the answer to the following question: Do you have carpal tunnel syndrome, or a different repetitive strain injury? The following is an excerpt from "3 Minutes to a Pain-Free Life," By Dr Joseph Weisberg & Heidi Shink, which you can read online here.












This is the test the doctor gave me, and it seems to be pretty well accepted. REMEMBER: IF YOU DON'T HAVE CARPAL TUNNEL SYNDROME, your pain is still real! Don't let doctors or friends dismiss it. Other RSI's (Repetetive Strain Injuries) can be just as debilitating. Read more about RSI's here.

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