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This is the FAQ for the RSI-UK mailing list. The initial version of the FAQ was written mostly by Douglas Hall in May 1999. Since then there have been a few additions and amendments, but at present (12/06/2000) the FAQ is not being maintained or regularly posted or updated. However, most of the information in it should still be valid.

As most people who will be reading this FAQ will have got RSI through keyboard use, the information and advice is angled towards this set of sufferers. However most of the information/advice will apply to people with RSI from other causes.

Advice given on the internet is no substitute for expert medical advice. Always consult your GP.

1. Changes since last posting, marked #
2. What is RSI?
3. What are the symptoms of RSI?
4. What causes RSI?
5. What are Adverse Neural Dynamics?
6. What are trigger points?
7. How can I prevent my RSI getting worse?
8. What treatment can I get for RSI?
9. Is it psychological?
10. What support is available in the UK?
11. What is RSI-UK?
12. Where can I find information about RSI on the Web?
13. Are there any good books on RSI?
14. Further Information

None.

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RSI is an umbrella term for a collection of conditions affecting the neck, shoulders, arms, wrists and hands. It can also affect the legs and feet. If you use your hands and arms a lot, e.g. keyboard use, you get it the in upper limbs; if you use your legs and feet, e.g. sewing machinist, you get it in the lower limbs.

RSI is also called by various other names, including:

• Occupation Overuse Injury (OOI)
• Cumulative Trauma Disorder (CTD)
• Work Related Upper Limb Disorder (WRULD)

There are two forms of RSI:

1. 'Distinct' RSI

   This includes: Carpal Tunnel Syndrome (CTS), Tennis Elbow (Epicondylitis), Tenosynovitis, Tendinitis, Bursitis, Thoracic outlet syndrome, Cubital tunnel syndrome etc. Health care professionals who deal with RSI tend not to call these conditions RSI but by their separate names.
   
   

2. 'Diffuse' RSI

   This is where you get multiple areas of diffuse pain in the muscles and other soft tissues. It is due to nerve compression (AND), trigger points etc. When health care professionals who deal with RSI talk about RSI this is what they are referring to.

You can have both of these types of RSI at the same time and multiple occurrences at the same time.

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• Tenderness and pain in the neck, shoulders, upper back, upper arm, elbows, forearms, wrists or fingers.
• Swelling in the hands or forearms.
• Tingling, numbness or loss of sensation.
• Muscle spasms or weakness (including loss of strength of grip).
• Difficulty using hands for numerous domestic, work and personal tasks (including turning pages of books or magazines, carrying or lifting things, turning doorknobs or taps or keys, holding a coffee mug, etc.).

RSI is a progressive condition, it starts with mild pain or tiredness of the hands, arms etc. during the working day, getting better overnight. Progressing to the pain and tiredness persisting overnight, but getting better after a few days break, to finally persistent pain which does not go away even after complete rest.

The earlier treatment is commenced, the better your chance of complete recovery. In the later stages, complete recovery is not always possible although symptoms can be reduced with treatment.

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There are several factors that predispose people to developing RSI:

• Posture: how you sit at your computer or go about your daily work. Static posture, sitting with your upper body held in one position all day, is particularly bad.
• A badly designed work station or work environment.
• Other medical conditions: dislocated shoulders, fractures, etc.
• Double use: working on a keyboard all day then going home and practising on a musical instrument, or knitting etc. (Your arms don't get a rest.)
• Stress: do you have a bad boss? do you hate your work? are you under a lot of pressure? are you likely to lose your job? All these can increase your likelihood of developing RSI as well as suffering more colds etc.
• Workload: just the sheer volume of work. Do you have to work through lunch or stay late to finish your work? Do you take breaks from your work?
• Type of personality: are you a conscientious worker? Do you work through your lunch break, stay late to finish your work? You are more likely to get RSI.
• Nerve damage: research published in February 1998 showed that all intensive keyboards workers suffered from nerve damage. However, only some of them suffered from RSI. Current research is trying to find out why.

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Adverse Neural Dynamics (AND), sometimes called Adverse Neural Tension (ANT) or Adverse Mechanical Tension, probably occurs to some extent in all cases of RSI.

This is where the nerve (in the arm, shoulder etc.) becomes tethered. This means the nerve cannot slide in its protective sheath and so causes pain, tingling, misfiring of the muscles and spasm. The nerve can become tethered due to a pressure point on the nerve or damage to the sheath it runs in.

The original cause of the tether could be due to muscles being tight and scrunched up. This is often the case with RSI and happens because of the static posture you sit in at a keyboard. As the muscles are tight it restricts the blood supply to the them and results in them getting fatigued. Eventually the muscles stay in this fatigued state as the never get to relax and have the blood supply restored. Surrounding muscles become tight to support the fatigued muscles and the problem spreads.

Tight muscles also press on the nerves as they pass through/around the muscle group, causing a tether. It also results in restriction of the blood supply to the nerves which prevents them from functioning properly and can eventually cause the nerves to send pain signals to the brain.

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There is a condition called myofascial pain which is caused by trigger points. Trigger points are small areas in a muscle which when pressed cause pain in other parts of the body. When they are active the referred pain is there all the time and gets worse when the trigger point is pressed. Trigger points can cause shortening of the muscle they are found in. They are often overlooked in the diagnosis of many pain conditions and are mis-diagnosed as other pain conditions.

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• The earlier you seek treatment the more likely you are to make a full recovery.
• Change of aggravating work practices.
• Use voice recognition - see http://www.voicerecognition.net/.
• Make sure you have an ergonomic assessment of your workstation. This is required by the Display Screen Regulations (1992), under the Health and Safety at Work Act (1974). You can get a copy of booklet L26: "Display Screen Equipment Work: guidance on the 1992 Regulations" from the HMSO for about £5, or if you're in a union your shop steward should be able to lay hands on a copy.
• Chairs and desks should be adjusted so they are at the correct height for you, your feet must be flat on the ground - use a foot rest if needed.
• Mice - make sure the mouse is straight in front of you, don't use it with your arm way off to one side. There are alternative pointing devices available.
• Keyboards - try changing to a different keyboard. There are quite a few 'ergonomic' keyboards available that may help.
• Monitors - should be directly in front of you, the top of the monitor should be just above eye level.
• Some people find arms on a chair help, others don't. If you do have them make sure they are at the right height and are padded. If you use a wrist rest in front of the keyboard, only rest your hands on it when you are not actually typing.
• Take regular breaks, including micro-breaks every few minutes. If you find it difficult to take your breaks put an alarm clock across the far side of your office, set it to go off in 20 minutes. When it goes off walk across the office and re-set it. You could use a break reminder program. Micro breaks are where you relax for a few seconds while sitting at your computer.

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When you go to see a doctor or other healthcare professional write down the symptoms you have, consider the following questions:

• Where exactly do you have the pain? - in your arms?, hands?
• What sort of pain? - aching?, tingling?, burning?
• How long have you had pain? - weeks?, months?
• Are you in pain all the time? or just when you do something?
• When is the pain worse? - morning?, evening?
• Do your hands feel cold? or sweaty?

Diagnosis of RSI is diagnosis by elimination. Everything else is tested for and if your doctor cannot find anything wrong then you probably have RSI. Your doctor will have to rule out things like rheumatoid arthritis and heart problems so don't be surprised if they get you to have a lot of blood tests.

There is no 'Cook Book' approach to treating RSI as each person has different problems caused in a unique way. However the person treating you should look for problems with your neck and shoulders as well as with your arms and hands.

When you are referred to a specialist or see a therapist always ask: "How much experience do they have in treating RSI?"; "How good are they at treating RSI?"; "How does this treatment work?"

Always check for the relevant qualification when seeing any therapist outside the NHS. Also ask to see a current insurance certificate, this is a good check to see if they are qualified.

• Your GP is your first port of call. They will refer you to the relevant specialist, either a consultant or physiotherapist. They will also know of the local private health care professionals and can guide you in selecting one of these. If you are claiming on Private Medical Insurance then your GP will have to refer you to the healthcare professional.

  The consultants you are likely to see are:

  • Orthopaedic surgeon (surgical specialist in bones and muscles)
  • Rheumatologist (specialist in diseases of joints and muscles)
  • Neurologist (specialist in nerves);

  The consultant may get you to have some x-rays and possibly a Nerve conduction study (NCS) or EMG test.

  Try to get a referral to a neurologist or rheumatologist who has a special interest in RSI as many do not have the experience in treating RSI satisfactorily.
  
  

• Nerve conduction studies (NCS) and EMG tests

  In the NCS an electrode is connected to a point in the hand, and a small electrical current is passed through the arm. The speed of the nerve responses can then be determined. Any time delay picked up along the nerve may suggest there is a problem.

  A similar test is done on the muscles which is called an Electromygraphy (EMG) test. In this test an electrode is pushed into the muscle, and then the muscle is tensed up. The level of electrical activity that is recorded can give an indication of any muscle weakness or wastage.

  Both tests only take a few minutes to complete and for most people they are not too painful. However, most RSI sufferers record a normal response.
  
  

• Diagnostic Imaging

  You may have an X-ray taken to check for skeletal problems, for example of the wrist or the back and neck and to check for an extra rib in the case of thoracic outlet syndrome.

  An MRI scan might be taken to assess your shoulders or back/neck, however any MRI scan is expensive so it is unlikely.
  
  

• Pain Clinics — normally run by rheumatologists. Look for one which does pain management not just pain relief. The INPUT pain clinic at St. Thomas's hospital in London is one. Normally they only accept you after you have suffered from pain for more than six months.
  
  
• Physiotherapy — normally the first treatment you will get.

  On the NHS, most physiotherapists only do 6 sessions maximum before you need to see your GP or consultant again.

  The physio you see should have experience of treating RSI, they should know about AND, trigger points and manipulation of the back. If you are selecting a physio for private treatment (or indeed on the NHS), then you need to ask if they have the relevant experience.

  The physio should test for: AND, trigger points, back and neck problems. They should also look for any postural problems. The treatment you receive will depend on what is wrong with you, it can be: AND stretches (the physio will 'twist' your arms around and teach you some stretches to do yourself); ischaemic compression on any trigger points (with more stretches to do yourself); ultrasound to reduce any swelling, TENS to reduce any pain and joint manipulation to re-align the vertebrae. They may also carry out some acupuncture on you.

  Intensive physiotherapy including lifting weights is likely to make your RSI worse.
  
  

• Occupational Therapy

  You may be referred to occupational therapy by a doctor or by social services. Occupational Therapists will provide education on the condition, joint protection, ways of conserving energy and promoting desirable habits in personal and domestic tasks, leisure, and work including looking at bad ergonomics. They will develop a home program to include: wearing splints, exercise and rest breaks plus all the above points. They will also help find you aids to help you in your home.
  
  

• Chiropractic and Osteopathy

  Chiropractors and osteopaths manipulate joints and muscles which help with a wide variety of conditions, especially neck and back pain. There is usually a great deal of overlap between chiropractic, osteopathy and physiotherapy treatments. Chiropractors tend to take more x-rays, whereas osteopaths use massage in addition to manipulation.

  Osteopathy and chiropractic will have similar effects - they will work in some people, not in others. They are more likely to be effective where symptoms are less chronic.
  
  

• Alexander Technique — is good for problems with the back/neck/shoulders and to improve your posture.
  
  
• Relaxation/Meditation — to help reduce the stress in your life.
  
  
• Exercises
  • Swimming — A good exercise for the whole body without putting too much stress on any one part. However don't do breaststroke as you have to support your head in a strange position which puts a lot of strain on the neck.
    
    
  • Walking — go for a brisk walk as it increases the blood flow, endorphins etc. This reduces the pain and gives you something to do. Keep your hands in pockets to take the weight off your shoulders if you need to, otherwise swinging your arms as you walk can help.
    
    
• Operations — a last resort. CTS release is the most common, but must only be carried out after a nerve conduction test to prove you have CTS.
  
  
• Drugs — Pain killers, NSAIDS

  Buy the generic drugs rather than the named brands, they are much cheaper and have exactly the same ingredients.

  The common over-the-counter ones are: paracetamol (take care not to exceed the stated dose) which does not have any anti-inflammatory effect; aspirin and ibuprofen which can cause stomach problems.

  Don't take pain killers to mask the pain so you can continue working. You will just make your RSI worse and more difficult to treat. Do take pain killers when you go to bed so you get a good nights sleep and are relaxed, not fighting the pain, when you are asleep.

  Tri-cyclic anti-depressants can be used as pain killers as well as for depression.

  Anti-inflammatory gels can be rubbed into the area of inflammation or pain and get round the risk of stomach problems.
  
  

• Steroid injections — avoid if at all possible, they don't have a long term effect unless you stop the activity that causes the problem. Can have some bad side effects, and you can only have a limited number of injections into the same site.
  
  
• Ultrasound — useful to reduce swelling and can help reduce trigger points.
  
  
• TENS — temporarily blocks the pain signals in your nerves by stimulating the nerves with electrical pulses.
  
  
• Trigger points — treated by ischaemic compression, acupuncture or stretch and spray. You should be taught some stretches to prevent them re-occurring.
  
  
• Heat — improves blood flow to the heated area. Use infra-red lamps or heat packs to warm the required area.
  
  
• Ice — reduces inflammation and stimulates blood flow in the iced area. Apply ice packs or a bag of frozen peas to the required area.
  
  
• Acupuncture — works wonders for some people, has no effect for others.
  
  
• Splints — only wear on the advice of a physio. Don't wear them all the time as it can lead to atrophy of the muscles. The body also needs to keep moving to work properly. Wear them when you are resting or at night.
  
  
• Massage — If it does not make your condition worse (it may hurt a bit when it is being done — even when you are completely normal) then massage is very good. It improves the blood flow, releases toxins and makes you relax. Have your back/shoulders/neck/arms/hands massaged as often as possible. If you have a partner buy them a good book on massage as your birthday or Christmas present or go to an evening class together to learn. The sufferer must not do any massaging themselves as it will aggravate the condition.
  
  

  Qualifications for massage vary from the basic swedish massage and aromatherapy through to remedial massage which requires a higher degree of training.
  
  

• Rest — Reduce or even remove the aggravating factor from your life, however don't rest completely. The normal movement of your arms keeps the muscles/tendons/nerves 'lubricated'. When you rest your arms, any part of them that has a problem will no longer be getting the gentle work-out it requires to keep it functioning normally. In mild cases of RSI rest is all that is needed to make the pain go away. However complete rest can make your condition worse.
  
  
• Adverse Neural Dynamics stretches

  AND is treated is by a series of stretches for your arms which stretch the nerves and removes/relieves the tethered points. Doing the stretches relieves the pain because it untethers the nerve and allows it to slide freely again.

  Your physio will tell you how to do these. He/She should also teach you exercises to mobilise your back/neck as a lot of RSI sufferers have problems here without realising it and these can cause symptoms in the hands and arms.

What I found good for treating my AND and associated RSI problems was:

• Learn the AND stretches and do them as often as you can.
• Find a good masseuse/aromatherapist to get any knots out of your back/shoulders and try trigger point therapy for any residual pains.
• Take up the Alexander Technique to improve your posture.

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Q9.1.
My doctor says it is all in my head. What do I do?

If it is your GP then:

If you are in a group practice try seeing one of the other doctors in the practice. Doctors' sympathy/interest varies greatly within a practice. If you have no luck, then transfer to another practice in your area. You are entitled to do this. Before you join, interview the doctors at the new practice to find out their attitude to RSI.

If it is the consultant:

You are entitled to a second opinion, so ask for one, but not from one of your consultant's best mates!

Q9.2.
I feel that my doctor thinks it's all in my head — or else that I'm just inventing it — even though he doesn't actually say so.
I get the same feeling from my boss and from my work colleagues and even from some of my friends/family. Am I going crazy?

Keep pressing the doctor about treatment possibilities, ask informed questions, and try to describe the pain as accurately as you can, erring on the side of understatement rather than overstatement. Get the PACT team in to talk to your employers about how you can be helped to return to work -- the PACT team will assume you are telling the truth, and that may help convince your employer. In the meantime, try not to take the scepticism personally, and remember that if the positions were reversed, you too might be feeling some doubt. Everyone who suffers from an "invisible" ailment has to cope with this to some extent.

Q9.3.
I can't sleep, I can't eat, I don't feel like seeing anyone or doing anything. Even when the pain goes away, I don't feel any better. Am I going crazy?

You may be suffering from depression. RSI can bring a lot of problems with it: physical pain; short-term and long-term financial anxieties; anger about being treated unfairly by employers and healthcare professionals and colleagues; loss of independence; isolation; loneliness; and fear. This is a lot to deal with all at one time, and the strain can lead to depression.

If you have any of the symptoms of clinical depression, it's essential to talk about it with your GP. It will be much harder for you to recover from RSI as long as you're depressed. Anti-depressants can help, though you may have to experiment (under medical supervision) to find the right one. Support groups (whether for RSI or for depression) can also help.

It may be suggested to you, by your GP or by others, that the RSI is caused by the depression. While this is not impossible, it's important to remember that for most people it's the other way around: the depression comes about as a response to the many practical, financial, and social difficulties that can follow in the wake of a diagnosis of RSI. If your doctor wants to treat the depression but not the RSI, you may have to find another doctor; both problems have to be treated together.

Even if you're not clinically depressed, remember that it's perfectly normal to feel scared or lonely or angry when you're trying to recover from RSI. You're not the only one who feels this way; as you learn to cope with the physical problems, the emotional turmoil will calm down.

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Q10.1.
What benefits are available in the UK?

As a disabled person you may be entitled to several benefits:

• Industrial Accident
• Industrial Disease
• Incapacity Benefit
• Disability Living allowance

  None of these are currently means tested, but they do require a lot of form filling and possibly a medical examination. Some of the benefits only apply if you have certain recognised conditions. As the rules for claiming them change from time to time, contact your local benefit agency office for more details.
  
  

• Access to Work (DEA)
  Access to Work is a scheme designed to help disabled people stay in work or to get a job. It can help pay for the cost of additional equipment, for example voice recognition software. Your employer pays for the equipment you need then applies for a refund for most of the cost. To join the scheme get in contact with the Disability Employment Advisor at your local job centre, near where you work.
  
  

Q10.2.
What other support is available in the UK?

• The Repetitive Strain Injury Association (RSIA)

  The RSI Association provides information, support and advice to people with Repetitive Strain Injuries. The Association also promotes better understanding of the condition through research, publicity and campaigning.

  Please do join the RSIA!

  It currently has about 2000 members and publishes a quarterly newsletter. It provides a telephone helpline Monday to Friday 11.30 am to 4.00 pm.

  The RSIA can supply two information packs:

  • A general information pack on RSI, containing details on: What is RSI, how to avoid it, what to do if you get it, book lists etc. for 3.95 ukp including post and packing.
  • A Display Screen Equipment information pack which contains information about display screen equipment legislation, RSI and health and safety law and includes a worksation self-assessment questionaire. It costs 4.50 ukp including post and packing.

  To contact the Association:
  
  

  RSI Association
  380-384 Harrow Rd.
  London
  W9 2HU
  
  Tel. 0171 266 2000 (General enquires)
  Tel. 0800 018 5012 (Freephone helpline)
  

• There are approximately 30 local support groups spread around the country. Contact the RSIA for your nearest one. The RSIA also has a list of people throughout the country who are willing to talk to other sufferers.

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RSI-UK is a mailing list for the discussion of RSI from a UK perspective. The list is primarily intended for use by people living in the UK who either have RSI problems themselves, or are caring for someone with RSI, or are concerned that they may be developing RSI.

Q11.1.
What topics are discussed on RSI-UK?

Treatment; pain relief; social security benefits; legal aspects; coping techniques; adaptive equipment (such as ergonomic keyboards, pointing devices, voice recognition packages, break-reminder software, and workstation furniture); pacing techniques; and other RSI-related subjects. The list is non-commercial, and advertising is not allowed.

Q11.2.
Who subscribes to RSI-UK?

Mostly, people who suffer from RSI. Others with an interest in the subject, such as healthcare professionals, ergonomists, safety officers, lawyers, etc., are also welcome to subscribe; however, the primary focus of the list is the exchange of practical information and sharing of support between people who suffer from RSI.

Most RSI-UK subscribers have RSI as a result of keyboard use, but the list is for everyone who suffers from RSI, from whatever cause.

Q11.3.
How do I join RSI-UK?

To join, send an empty email to rsi-uk-join@rsi-uk.org.uk.

You should soon receive a confirmation request. If you reply confirming that you do wish to join the list, your address will then be added to the list of members; you will begin to receive the messages that other subscribers post to the list, and will be able to post to the list yourself.

A few tips about posting:

• Don't post attachments. They'll be stripped off.
• Don't post in HTML.
• Bear in mind that everything posted to RSI-UK will be archived (http://www.rsi-uk.org.uk/archive/), and this archive is open to anyone to read.
• Don't forget to mention any techniques, equipment, treatments or exercises you've found that have been helpful to you. Someone else might benefit from your experience.

The RSI-UK mailing list is kindly hosted by Loud-n-Clear Ltd.

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• The RSI-UK Website (http://www.rsi-uk.org.uk)

  RSI from a UK perspective. UK resources, recovery techniques, articles on various aspects, how to set up a workstation, related links, etc.
  
  

• The Typing-Injury FAQ (http://www.tifaq.org)

  Information on just about every imaginable aspect of RSI. Pointers to other sites around the world, product reviews, suppliers, software to download, and much other valuable information. The TIFAQ is based in the US and is maintained by Scott Wright.

Both RSI-UK and the TIFAQ include links to many other RSI-related websites. Bear in mind, though, that much of the information will be duplicated from site to site, and clicking can be painful. A targeted search (e.g., for information about trigger points) is likely to be more productive than random surfing.

There is no site which has the definitive answer to RSI.

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Get the following books through your local lending library or from one of the internet bookshops (the latter often sell the books at a discount).

• Still probably the best general guide on RSI:

  Repetitive Strain Injury
  Emil Pascarelli and Deborah Quilter
  Wiley (US), ISBN 0471595330, GBP 10.25
  
  

• A short but thorough book on RSI from a UK perspective:

  Coping Successfully with RSI
  Maggie Black and Penny Gray
  Sheldon Press, ISBN 0-85969-811-4, GBP 6.95
  
  

• Advice on treatment and prevention based on personal experience:

  Repetitive Strain Injury: a handbook on prevention and recovery
  David Ruegg
  Largo, ISBN 0-9534718-0-2, GBP 7.99
  
  

• A simplified book on trigger points:

  Pain Erasure: The Bonnie Prudden Way.
  B. Prudden
  Ballantine Books (US), ISBN 0345331028, GBP approx 7.30
  
  

• A good and cheap book on anatomy:

  The Anatomy Colouring Book
  W. Kapit and L. M. Elson
  2nd Edition (the 1st edition has some errors in it)
  Harper Collins, ISBN 0064550168, GBP 10.00
  
  

• A good book on pain by two of the leading researchers:

  The Challenge of Pain
  R. Melzack and P. Wall
  Penguin, ISBN 0140256709, GBP 10.00
  
  

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For more information on any of the subjects covered by this FAQ look in the RSI-UK Website (http://www.rsi-uk.org.uk), post a question to the RSI-UK mailing list or check out the RSI-UK mailing list archive (http://www.rsi-uk.org.uk/archive/).

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