The article indicates that RSI is part of an ever increasing phenomena affecting 115,000 workers last year a staggering 34% increase from the previous year. If ever we needed evidence that RSI is reaching epidemic levels, then this is it.

It also contains a quote from Pauline Cole (a spokesperson for the Association of Chartered Physiotherapists in Occupational Health and Ergonomics (ACPOHE))

“A lot of people are using computers more, even in jobs you wouldn’t traditionally expect it”.

This is the trouble with RSI conditions. Just about every job these days requires interaction with computers, and this can present major challenges when a worker is affected with RSI, there are few options out there to allow them to work whilst avoiding computer use and allowing their bodies to recover, except for perhaps manual labour.

In another revealing quote from the article, this time from Bunny Martin (who runs charity Body Action Campaign)

“schools tend to have a single standard computer set-up for nine and 15-year-olds alike.”, and alarmingly she notes that “around 60% of children she meets have first symptoms of RSI, including strain-related pain in the neck and shoulders.”

This is a staggering fact and if RSI is impacting children years before they start looking for employment then we truly are sitting on a RSI health time bomb.

All in all an excellent summary article on where we are at with RSI.

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Whether this form of computer input technology will ever see serious light of day or not, or whether it will replace the keyboard and mouse, is anyone’s guess, but it is interesting to see trends in technology moving away from using the standard devices (although it is hinted that currently there is no good replacement for a keyboard for text entry).

Whether this technology can save us from RSI related injuries is open to debate; it may well transpire that they just mean we are susceptible to different types of injuries, but it is a good sign that developers are at least rethinking the now traditional methods of interacting with computers. It could lead to opportunities in computer use for people with all kinds of different disabilities, and not just RSI.

Is this the start of a new age in ergonomics, or is it just the latest phase of hi-tech gimmickry ?

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The common position for hands hovering above a keyboard is as shown on the right, which I refer to as the ‘claw’. This position elevates the tension in the aforementioned extensor muscles, causing them to become fatigued over prolonged periods of time. Typing whilst the hand/wrists are in this position (another common posture mistake) will further increase the muscle and tendon stresses making the situation worse.

What may not be so obvious is that moving the wrists into a more neutral ‘level’ position (see image) can still create enough continual tension in the forearm extensor muscles. This is not always apparent unless, like me, you already have a bad RSI condition and can notice the pain in already injured muscles.

This is a much better position than the ‘claw’, and the forearm extensors are far less tense. They are however still in tension which may lead to forearm extensor fatigue when held in this manner for long periods of time eg 6-8 hours a day hovering your hands over a keyboard at work.

The final image on the right shows a ‘hanging’ wrist position which, if adopted, places minimal stress on the forearm extensors, (they should in fact be relaxed in this position), and is a good posture to aim for when typing. You can then utilise the weight of your hands and fingers to type, lifting the arms from the shoulders and elbows instead of placing the burden on the forearm extensors and associated tendons.

You don’t even need to be at a keyboard to try out these different wrist angles. Just hold your hands in these positions for 2 minutes and observe the different tensions in the forearm extensor muscles. Start to imagine what it is like for your body to hold this tension for up to 8 hours a day at a computer, and ask yourself whether it may be more beneficial if you changed your posture to one that has far less muscle/tendon tension in it.

Note: In order to successfully utilise the ‘hanging’ wrist position you will most likely need an ergonomic computer set up with a drop down keyboard tray, perhaps even an adjustable position keyboard tray.

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OK, so you are experiencing a long term RSI condition, ie it has gradually worsened for more than 2 years. You are in continual pain at work and find it difficult to do your job. You have perhaps gone through consultations with ergonomists, doctors, physiotherapists and just about anybody who’ll listen, but still you find no relief. You struggle to remember what it felt like not to associate pain with computer use. You may be wearing an arm brace (and probably have a large collection of them by now), and you probably have a sizeable collection of strange ergonomic mice at your computer that don’t seem to help. Your employer keeps expecting the same work output from you and you stress about how you can get through it. You get by by doing what you can, but generally come home each night from work and feel anxious about the situation and the searing pain down your arms. You wonder what you can do, and how you are supposed to live a normal life – you can’t remember what normal life was like before this injury!

So what are the options then? Well I remember a great bit of advice from my father (that’s what fathers are for after all). It was at the stage where I was still living in the US and wanted to return home. The prospect of a new computer intensive job and a new situation was looming, and I wondered how I’d cope because my injury was getting worse. The stress of the situation wasn’t helping either and changing countries of residence can be a very anxious time. I just wasn’t sure whether I could go on working with computers any more. I phoned my father and told him the situation, fully expecting him to tell me to stay with the job. I was, however, surprised when he said rather straightforwardly, “Well, you’ll need your arms and hands for everything else you decide do in life”. In other words, it wasn’t really an option to keep doing something that could ultimately make me any more disabled. I knew then that I had to consider doing something else.

Before coming to any radical decisions, I really strongly recommend trying to adopt all the suggestions in RSI – What to do? (Part 2 – RSI Dealing With Progressive Symptoms) in the majority of cases you will see improvements.

In addition I’d recommend -

• Eliminating as much computer interaction as possible at work, home and elsewhere
• Eliminate text messaging entirely
• Eliminate use of games consoles if you use them
• Get as physically fit as possible, go swimming
• Use meditative techniques to relax and ease the pain, maybe as part of a Yoga class
• De-stress your life wherever possible
• Get at least 8 hours of sleep a night
• Stick to core work hours – if you are in really bad, continual pain, consider medical leave
• Talk over options with your employer – there may be something else less computer intensive that they can find for you to do
• Find a good physiotherapist who can do deep tissue massage
• Find a RSI support group and share your experience with others. Hear what has worked for others and get free helpful advice
• Consider a career change – it’s tough to do and can be stressful in itself, but there are still jobs out there that don’t require computer use, or at the very least involve less computer use. I am now a self employed picture framer!

RSI conditions can be tricky to get rid of. I have been away from my computer intensive career for two years now, and I still have bad RSI symptoms. Interaction with a computer for 5-10 minutes can make it start to hurt badly, so these conditions are not easy to shake off. There is no ‘magic bullet’ to fix them.

Look after your arms and hands, remember you will need to use them in any new career you decide to take. Good luck with finding a solution that works for you.

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The symptoms have been described by a few physicians to me as tennis elbow like in nature. The tight and spasming extensor muscles and tendons end up being over used, and don’t get the chance to recover. This leaves them in a permanently fatigued state, tightly tensioning the forearm tendons to which the extensor muscles are attached, causing referred pain down the tight tendons into the hands and fingers.

You can do a check to see how fatigued your forearm extensor muscles are. Using your left hand to check your right forearm extensor muscles press down firmly with the thumb onto the upper forearm extensor muscles (see image below), move the position of the thumb slightly over these muscles and check for pain. Repeat the diagnosis with the left arm extensor muscles and your right thumb.

If you are in any doubt about what these muscles do, press your thumb on your arm as above and raise your wrist up as if you were about to type. Also raise and wiggle your fingers. With your thumb, you should be able to feel your extensor muscles tightening as your wrist and fingers raise.

If you find the extensor muscles to be in pain with the above procedure then these muscles are fatigued. It also means that ergonomically, you are not using your keyboard properly and are probably typing using the claw, which causes this type of problem. This type of condition is one of the most common mechanisms for RSI pain, but can easily be addressed by changing the way you type.

If you are experiencing pain in these muscles, it is time to try to relieve them which can be done by massage, icing and rest. Consult your doctor or a trained physiotherapist to find out the best techniques which may include ultrasound. It is also time to re-assess your typing technique otherwise you may be placing yourself at risk of an RSI type condition. This may send the forearm extensor muscles into a more permanently fatigued state, from which recovery may be difficult, and in some extreme cases may be impossible.

In my own case, forearm muscle fatigue is the primary mechanism for my RSI pain. Unfortunately for me, I learned of the prevention techniques several years after my symptoms began, when these symptoms had already become more permanent. To this day I still have not been able to understand what condition these misused muscles are in, but I suspect permanent damage. I do however still get some much needed temporary pain relief these days from massage of the forearm extensor muscles and tendons, just not very lasting , but my injury is after all a long term one.

See also my other article on forearm extensor muscle overuse and wrist positions.

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The biggest problem with the invention of the mouse, and for that matter all current GUI based computer systems, is that they force a user to do a very repetitive motion that had up until their invention not been done before, ie the repetitive small movement of the index fingers to send a ‘click’ to the computer to say ‘do this’. Sometimes this repetitive task can be very intensive (depending on the application being used). This has over the last 15 years or so led to a large increase in cases of Repetitive Strain Injuries (RSI).

So what alternatives to standard mouse ‘clicking’ exist right now for the computer user? (Note: the following is by no means an exhaustive list)

• keyboard short cuts
• voice recognition software
• foot pedal clicking
• graphics tablet/tablet PC pen “taps”
• software generated clicks
• touch screen monitors

Each of the above have their own set of positive as well as negative points. The following is a brief summary of what I’ve found from my experiences with each of them -

• Keyboard shortcuts -these are quick access (single or combination) keyboard strokes which activate a command without moving (or clicking) a mouse and can greatly reduce the amount of mouse use required to do certain tasks. There are keyboard shortcuts available for most of the operating system versions around including Windows (9x, 2000, XP, Vista), Linux (KDE, Gnome) and Mac, as well as most of the applications that run on these operating systems. I have indeed found many keyboard shortcuts to boost my efficiency when using some software applications. Indeed without these shortcuts I would have been only 50% as productive at my job as I was! However the biggest limitations to keyboard shortcuts are as follows -
  • They are not well publicised, and as such there is a general ignorance out there as to their existence
  • The shortcuts may be common in a certain operating system, but not always transferable from one platform to another.They are rarely common across applications apart from very common tasks eg copy and paste etc.
  • A lot of applications could be more productive if more of their menu commands were available as keyboard shortcuts
  • There is a lack of ability for a user to customise the shortcuts in these applications.
  • You often have to continue to click a button to activate things, eg hit ‘return’ key or mouse click.
  • You still have to use your hands on the keyboard
  • Keyboard short cuts themselves are also repetitive in nature, and can cause RSI conditions in their own right.

• Voice recognition software – In my own experience, voice control software has always had great potential for relief of over-used arm and hand muscles, however, the effort involved in learning how to use the software, ie teaching the software to recognise your voice is a soul destroying and often futile task (I have had a lot of frustration in my numerous attempts!). Unless someone comes up with a version for a low toned, Scottish speaker, I see it as of little practical use to me personally. The last thing you want to do around an office is talk in a loud distinct and clear voice anyway! You will start to get strange looks from your co-workers!
• Foot pedal clicking is certainly a viable option. There are a few foot controlled ‘mice’ out there. Whilst I can’t be enthusiastic about mouse movement control with a foot mouse (my ankles started to hurt when I tried this motion), the clicking action could easily be done by foot, although double click timing could be an issue.

• Graphics tablets/tablet PCs – these input devices give the user an option to use a special pressure sensitive pen to move about a ‘tablet’ surface. This action is akin to holding a pencil whilst writing. This a relatively natural position which we have been used to ever since we learned to write. The clicking action is either controlled by clickable switches on the side of the ‘pen’ or by ‘tapping’ the pen tip against the tablet. This is indeed a complete change from standard mouse clicking action, but still involves many small repetitive movements (mainly wrist based) for clicking, coupled with a tight grip holding onto the pen. I also find the tablet surface (and edge) itself to be a cold and hard surface to rest my hand, wrist and arm upon. They can also take a bit of getting used to. Personally, as an RSI sufferer, I found the wrist motion to control the pen taps to be too painful to use on a regular basis. My injury may well have progressed too much by this stage, and the continual need to grip the pen also didn’t work for me. It may, however, be a viable alternative to a mouse for many other computer users.
• Software generated ‘clicks’ – This method has intrigued me for a long time. There is software available that can be used to generate a mouse click. The trigger for a click is the movement of the mouse followed by the stopping of the movement for a pre-determined time. This is usually indicative of the user hovering the cursor over a button etc that needs a click to activate. The software can be user controlled to send left, right, centre, double etc mouse clicks, which can be an absolute life-saver for some RSI sufferers (myself included). One such piece of software available (for free!) is ‘Point-N-Click‘ by Polital Enterprises. The use of this type of software is great for certain types of common applications eg web surfing. They can of course detect an unintentional mouse movement and send an unintentional ‘click’. This is often not important, but can have implications if, for example, you accidentally send out a mail message to someone prematurely (as I have done). Fortunately, there are sensitivity and delay controls available to tailor the software’s response to your individual needs. ‘Point-N-Click’ also has a built in “take a break” reminder alarm, which is very useful. Even better, the software is currently free, so you can try it out for nothing!
  Alternative mouse click generation software are ‘Nib‘ (formerly free software called mousetool) by Designer Appliances, and ‘Gentle Mouse‘. Neither of them are free, however you can evaluate both with time limited demo versions. Gentle Mouse has the added benefit of not sending clicks until you move the mouse a second time to choose either left or right clicks, the advantage being the reduction in the number of erroneous clicks you send.
• Touch screen monitors – I have not yet experienced a touch screen monitor. They certainly may be a very usable option for an RSI sufferer. I personally still feel that I’d be tapping my fingers against a surface yet again, which for me would still most likely lead to pain. It could, however, be a viable solution for many computer users out there, and looks like a promising development in computer input devices.

As is often the case, there may not be a single solution to combat RSI. It may be more sensible for an individual to choose a few different methods of control, and switch between using them. The key thing is to avoid doing any one repetitive action all of the time.

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Having seen what manufacturers ship with their systems, I would be a proponent of legislation to ensure that the basic minimum mouse is an ergonomic one. By ‘ergonomic’ I mean that it meets certain standards with respect to shape (comfort to hold on to), button (click) pressure, and optionally be available in different sizes to accommodate different hand sizes. Unfortunately, in the cut-throat cost driven PC market these days, this is unlikely to happen without legislation.

Some tips I have learned over the years regarding mouse use is as follows -

• Try changing hands when using the mouse. Do it frequently (eg once an hour) in order to rest the other hand. Have a second mouse installed at the left hand side of the keyboard (if you can’t be bothered moving the original one)
• Consider having 2-3 different styles of mice, and use each style for 1/3 of the day. This will change the motion of the fingers/hands to something different, and may help to break the cycle of repetitive motion associated with using a single mouse.
• If you are having RSI symptoms already in your mouse hand, try obtaining 2-4 different styles of special ergonomic mice or alternative input devices and cycle through them for 1/4 of a working day at a time. Try to ensure that each mouse/input device operates differently especially the clicking motion. eg. 1 input device std right hand forefinger click, 1 input device right hand thumb click, 1 input device left hand forefinger click, 1 device left hand thumb click.
  This variety will maximise the resting time from the motion that is causing your specific RSI problem. If in doubt about input device choice, consult an ergonomist.
• Consider trying out an alternative input device(s) entirely eg. graphics tablet, tablet PC, Contour Roller mouse, touch screen monitors , or the use of one of these with a standard ergonomic mouse. Alternatively you can wait for future developments in technology like the microsoft surface or the 3d motion sensor camera by 3DV Systems which I’d like to try out, although it remains to be seen whether such a device will be purely aimed at the gaming market as opposed to the general PC market

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A very common bad ergonomic practice is wrist deviation when using a keyboard. Keyboards have never been the most ergonomically designed devices, and users tend to hold their wrists very central to the keyboard whilst inducing a lateral deviation in their wrist angle.

Lateral (ulnar) deviation can eventually lead to wrist pain, both centrally and at the outer edges of the wrist. This can occur due to nerve pinching and tendon compression which can ultimately lead to RSI like conditions.

The image on the left shows lateral deviation in both wrists. This deviation can be further worsened by the user reaching for keys at the more extreme end of the keyboard, most commonly by little lateral wrist ‘flicks’.

This is a very common ergonomic problem, and can be easily rectified by the user once they know what to look for. The biggest problem being that most
users don’t start paying attention to wrist deviation this until pain develops.

Keyboard Position

Keyboard position can become critical too.

An off-centre keyboard can cause one wrist to laterally deviate more than the other. Keyboards should have the centre of the spacebar (as opposed to the centre of the keyboard) aligned to the user’s centre. This will push the numberpad (if you have one) way out to the right, but will reduce the lateral wrist deviation.

Alternatively keyboards with removed numberpads (which are not always used) are available.

Good neutral wrist angle

It is very important to have your wrists in a neutral position when using a keyboard. Compare the wrist deviation angle in the image to the left. The wrists are held in a neutrally straight angle.

This is the best angle to hold them in to minimise potential injuries. This may feel a little strange at first, but keyboard users can get used to this style of typing posture. The hands should be lifted by the forearms and shoulders and no pivoted by the wrists. Keep in mind at all times to avoid clawed hands.

Keyboard solutions

Alternatively, there are a wide array of ergonomic ‘natural’ type keyboards, which present the keyboard to the user at the optimal wrist angle.
Some, like the GoldTouch keyboard (pictured below) have a fully adjustable split that can be adapted to the user’s posture.

This keyboard has the right hand number entry pad removed, but if required, a detached separate one is available

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The prevalence is for keyboard users to use ‘clawed’ hands when using a keyboard to enter text. By this I mean when a user readies their hand position over the keyboard before they type, or whilst in thought between text entries, the hands can be seen to be extended into the air from the wrist in a ‘claw’ like shape (as pictured below). Often the wrists are leaning on a wrist rest, or worse still, leaning on just the hard desk surface .

Even worse, some users can actually continue typing with their hands in this claw like manner, with the fingers being held high over the keys like an eagle’s talons over it’s prey.

The risks involved in this practice can be significant when done over a continuous period of time. The forearm extensor muscles are in continuous tension, as well as the tendons over the back of the hands and fingers. If held tense like this for long periods, the forearm muscles can fatigue very easily, ie they are being used in a way that they were not designed to be used for over protracted periods.

Continuous use of this arm/hand pose over a keyboard or other input device can, if left unchecked, eventually progress to RSI like symptoms down the arms and into the hands and fingers.

This may be explained by the forearm muscles being tighter than they should be, which in turn creates tension in the tendons that control the hands and fingers, leading to pain in these tendons as well as the muscles that control them. In worst cases (like my own) the forearm muscles seem to have a very small usage threshold before chronic fatigue sets in and pain occurs. This is attributable on my part to many years of bad keyboard practice, and using the ‘claw’. At this stage, I’m unsure whether these muscles or tendons will ever fully recover.

Suggestions for keyboard users -

1. Do not use the ‘claw shape’ wrist when typing on any keyboard. Try leaving your wrists in neutral position with no wrist or forearm tension.
2. Try using the weight of your hands and fingers to hit the keys (not raising your individual fingers to do so.) This can be achieved by lifting your forearms/hands from the upper arms and shoulders as opposed to clawing the individual fingers back, which fatigues muscles and creates tension in tendons, ultimately leading to RSI like symptoms.
3. Examine you forearm muscles for signs of pain. Press your thumb into the forearm muscle tissue about 3 finger widths down from the elbow bone, and see if these muscles are sore when pressed. If they are, then you may be putting yourself at risk of RSI, and should change your ergonomic practices to reduce the forearm muscle tension.
4. You may need a keyboard height adjustment to reduce the forearm tension. This may involve installing a drop down keyboard tray for optimal position.
5. Some relief for sufferers can be gained by massage of the upper forearm muscles. This can be done by the sufferer by either using a thumb to rub deeply into the forearm muscles tissue, or by use of an electric hand held massager. Alternatively a sufferer can obtain professional massage from a physiotherapist. The pained forearm muscles in can respond well to massage, but relief may be temporary since the pain is merely the symptom and not the root cause, which is bad posture.

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