RSI at Harvard
UHS/Health Care Providers
Office & Study Equipment
Tips for Musicians
This section contains some tips about every day living.
While some specific products are mentioned in this section, it is not intended as a comprehensive guide to ergonomic products. We are sorry, but we are unable to evaluate or mention most of the products about which people email us. The Typing Injury FAQ provides a much more complete list.
Here are tips for long term sufferers. Some of these tips are also appropriate for those with shorter term injuries. These tips are not meant to be comprehensive. Also, check out the book "Repetitive Strain Injuries, a Computer User's Guide" by Pascarelli and Quilter. These tips are aimed partially at the Harvard student population, and meant to supplement other sources of tips. And don't forget to come to Harvard RSI Action meetings, where we exchange useful ideas!
Pascarelli and Quilter is usually available at Wordsworth 354-5201. You can call first to see if they have any in stock. If they do, it might be in either the health section or the computers section, so check both.
The handbook for teaching fellows is pretty vague on what accomodations need to be made for students; it is generally up to you, your T.F., and the professor. However, if you shouldn't type or write (ideally, as written in a note from UHS), don't type or write, even for exams. Students with other kinds of disabilities, such as blindness or deafness, are given reasonable accomodations for their needs, such as sign language interpreters, or someone to read for them. Ask for reasonable accomodation, which could include someone to take dictation for you in an exam, perhaps a T.F. For taking notes in class, ask the T.F. if you can have their notes, or ask another student in the class. If you can get a note from a doctor saying that reading is hard (flipping pages hurts), you can get books on tape, including text books.
This section assumes that your doctor is at Harvard University Health Services. If you go to a different doctor, this will apply to varying degrees. If you wish to find a doctor outside of UHS, there are two excellent resources. On the web, check out FindADoc at http://www.engr.unl.edu/ee/eeshop/findadoc.html. In Massachusetts, call CNOT, who maintain a referall guide.
For general medical advice on RSI, see the book "Repetitive Strain Injuries, a Computer User's Guide" by Pascarelli and Quilter, which is more accurate and more comprehensive than this section. In general, trust your doctor far beyond any advice you get on the web, including this page.
When you first go to UHS , you will see your primary care physician. UHS primary care physicians have received some training in RSIs, but certainly aren't specialists. (Elsewhere, most clinicians have likely received no training.) Try to get referrals to more knowledgeable people, depending on your symptoms. Several people in our group received incomplete or faulty diagnoses from their primary care physicians (though this may not be representative of people's experience at UHS in general). Since getting the proper diagnosis and treatment is very important, we strongly recommend getting a referral. If your symptoms are not very severe (e.g. minor pain only while typing -- goes away quickly), then you may not be able to get referrals. Instead, your physician will (or should) probably suggest rest, ergonomic changes, stretching, and exercise, as well as possibly splints, anti-inflammatories, ice, or heat.
In a classic case of tendonitis, with these changes, your symptoms should go away in about two weeks. In any event, schedule a follow up appointment so that if your symptoms do not go away, you can get more referrals.
Ask your physician for a note saying that you should not type, and diagnosing your condition. Have the note list other activities which cause you pain so you shouldn't do them such as writing or reading (yes, flipping pages and holding books open can hurt.) You will be able to give this note to teachers, teaching assistants, and the disabilities office. You may have to call UHS a few times to get the note. As always, be persistent.
If your initial problems are more than just minor, or your symptoms have not sufficiently improved by your followup visit, you will want to start getting referrals. The first referral you probably need to get is to physical therapy. The physical therapist is probably the most important person you can deal with. He will be able to teach you alternative typing techniques, stretches, and exercises. While some stretches and exercises are given on this web page, your physical therapist should be able to do a much better job, including a more extensive list of exercises and stretches, better tailored to your individual needs. For instance, some people need more work with their upper back muscles, while others need more work with their posture, while others need work with the hand. The physical therapist can also give you deep tissue massage and ultra sound, if appropriate.
Some people eventually get frustrated with the slow pace of physical therapy, and stop making appointments. Until you are either cured, or your doctor and physical therapist agree there is nothing else for them to do for you, it's probably a good idea to keep going back. First, if you are getting better, the physical therapist can give you more aggressive exercises. Also, your problems will probably move around a bit over time, and you can get new stretches appropriate to the new areas. Finally, if you're not getting better, the physical therapist can try more aggressive treatments, such as new stretches, harder deep tissue massage, etc. In summary, until you're cured, don't stop P.T.
Physical Therapy tends to get overbooked very quickly, with waits of four weeks possible. You should try to schedule appointments in advance if possible. Remember the four week lag, and keep enough appointments in the pipe line that the delay doesn't cause you to not get appointments you need. When you schedule your initial appointment for physical therapy, see if you can schedule one or two followup appointments. Otherwise, it could be eight weeks from the time of your referral to the time of your second appointment: a long time.
You should also try getting referrals to other more specialized doctors than your primary care physician if your problems persist or if you have serious problems, such as pain or numbness at rest. You will probably want to try getting referrals to an orthopedist, who will know a bit more than your primary care physician. You may also want to try to get a referral to a hand surgeon, who may know even more. If you have nerve problems, e.g. numbness or tingling, consider getting referrals to a neurologist. If your nerve problems are in areas other than just your hands and forearms, you should definitely try to see a neurologist. If your symptoms don't go away in a reasonable amount of time, you and your doctor should consider the possibility of other causes. These could include thyroid diseases, diabetes, thoracic outlet syndrome, arthritis, etc. So, getting a referral to a knowledgeable doctor who will have you tested for these diseases can be important.
Getting outside referrals at UHS can be very difficult. While your student health insurance will reimburse (up to a standard amount) for up to three outside referrals per year, (check with the insurance office: don't trust us!), you will need to get a UHS clinician to give you this outside referral. Some of them may be very resistant. Keep trying. Get internal referrals instead, and then ask the internal referrals for outside referrals. We may know physicians who are less reluctant, so contact us. You might try getting a referral to the head of orthopedics, who has more leeway regarding referrals. Change primary care physicians. Be persistent.
Kathleen Dias is the Patient Advocate. Consider asking her for help. On the other hand, you may also want to hold off talking to her, until you have tried other avenues within UHS. In one case, I asked the patient advocate for something, and my case was sent to Dr. Rosenthal, the head of UHS. When Dr. Rosenthal didn't give me what I wanted, it was more difficult to get it, since I had already gone all the way to the top.
A few of the treatments for RSI need some explanation. First, if you are told to use ice, be careful. Ice can tighten your tendons and muscles, so you shouldn't work after icing until you are warmed back up. Heat may be a better treatment, if it relieves your symptoms. (Ice and heat both cause blood to flow into the treated area. Ice can have more of an anti-inflammatory response, but has the tightening effect. Also, if you ice too long/too cold, eventually the blood flow is cut off, rather than increasing.)
Another treatment which requires care is wrist splints. If you use them all the time, your hands and wrists can atrophy quickly. If you use them while typing/working, they can put stress on other muscles/tendons. So, use them in moderation. (I like to use them while I'm running. Some people like to use them while sleeping if they have trouble sleeping in a good position or wake up with problems.) If your doctor gives you splints, ask him what activities you should do with them.
Finally, you should use anti-inflammatories (aspirin, ibuprofen, aleve, etc.) with caution. You should never do any activity while using anti-inflammatories that might cause you pain while not using anti-inflammatories: the anti-inflammatory may simply mask the pain, as you cause further damage. I've heard of people who work during the day, and then use anti-inflammatories at night to mask the pain: probably a bad idea.) If your doctor gives you a prescription strength anti-inflammatory or advises you to take an over the counter anti-inflammatory at a higher than usual dosage, watch out for stomach ulcers which are a possibility, especially with long term use. Take your doctor's instructions (often, to take the anti-inflammatories with food or milk) seriously. Most anti-inflammatories can cause stomach bleeding, which can actually be fatal. The signs include dark stools, and stomach pains. Ask your doctor/pharmacist about side effects. I'm told that Tylenol is not an anti-inflammatory, but only a pain reliever (and it typically doesn't relieve pain as well as anti-inflammatories).
UHS has a nutritionist who you can see for free. Poor nutrition could be associated with some problems, especially neurological problems, including low intake of certain vitamins, so this may be worthwhile. You might consider being tested for your levels of B-vitamins, or taking a B-vitamin supplement. But watch out: vitamins, being "natural", are less regulated than drugs; some over the counter supplements are actually not too far from the dangerous levels, so consult a doctor or nutritionist. Levels of vitamin B-6 over 100mg per day could be harmful for some kinds of nerve problems, such as carpal tunnel syndrome.
Don't buy a speech recognition product until you have tried out the ones that are available in the Adaptive Technology Lab. Speech Recognition is not right for every one. Some people get voice problems from it, or don't have the commitment to really get it working well. So, try it for free first. (Harvard used to get a discount on DragonDictate when it cost $700, but I don't know if this is still true.)
Try to get somebody else to buy the speech recognition equipment for you -- your advisor, your employer, etc. Don't think of this as a one time investment that you can afford: every year the technology gets better, and you'll want newer faster computers with better software, so if you can get somebody else to pay, you'll be happier.
Some people get voice problems while using speech recognition. A speech therapist recommended drinking hot decaf tea with honey (caffeine makes you urinate and dries you out). It is possible to develop vocal nodules (calluses on your vocal cords) which take a long time to heal; if you have problems while using speech recogntion, rest your voice! You might even want to consider seeing a voice trainer or speech therapist. Here is other advice you can try, from Eydie DeVincenzi:
The two major companies making dictation software are:
- Before you start a vr session, put a glass of _room-temperature_ water on the desk. Drink often during the session.
- Gradually increase the length of vr sessions.
- Stop when/if your throat gets tight. Soreness will quickly follow if you don't.
- If you experience soreness, stay off vr for a few days or until it's well healed.
- Start each vr session with some voice and throat exercises. Any singer or actor can recommend their favorites, such as "rolling-R-trills".
- Don't talk like a robot. Use natural intonations.
- Don't talk any louder than you normally do. If a misrecogntion occurs, don't raise your voice when you repeat the word.
Dragon Systems http://www.dragonsys.com/ (Dragon NaturallySpeaking and DragonDictate)
IBM http://www.software.ibm.com/speech/index.html (ViaVoice)
Most people find that Dragon products work best. They tend to work faster and faster as they get to know your voice well. Don't be discouraged if they are slow at first; eventually, they can type your words at 20 or 30 words per minute. While this may not seem fantastic, it is better than not using a computer at all.
The voice users mailing list is a high volume (about 30 messages/day) list which may be helpful. Their archive is http://www.voicerecognition.com/voice-users/archive/. To subscribe, see http://voicerecognition.com/voice-users/.
Joel Gould's Unofficial NaturallySpeaking Page http://www.synapseadaptive.com/joel/default.htm is indispensable for anyone using NaturallySpeaking.
Writing is a problem. Writing and typing share a lot of muscles, so if typing is a problem, writing probably is, too. Or, if you suddenly take up writing, you could easily overuse muscles that haven't been getting much exercise (was your hand ever sore after taking a three hour exam?) So, be careful. Be especially careful if you're in constant pain: it will be very hard to tell whether writing aggravates that pain, or not. It probably does.
In any event, try to find a pen that is especially easy to use. We have found that the best pens to use are pens that are very "fat" (i.e. have a large diameter) and that are also very light. Others like liquid ink roller ball pens. Finally, fountain pens can be especially easy to use. Experiment to find what works best for you.
One trick for making pens easier to hold is to build them up. Find foam curlers at your local convenience store. Throw away the curling part, and keep only the foam, which is cylindrical, with a hole about the diameter of a pen. Insert it over the pen, making a larger softer grip. I like to remove the clip part on my pens (the metal part for those who like to hold their pens in their shirt pockets.) The metal clip gets in the way of my foam curlers, so I remove it using a pair of pliers.
Proper writing technique can also help. Try to write using the large muscles of your upper arm. Make big movements. Write big. Don't grip your pen too hard. Try writing on a slanted surface (tilted with the top higher). Your physcial therapist can give you further instructions.
Elizabeth Wilmer, a former president of Harvard RSI Action, got RSI from writing. She recommends (in retrospect) a proper writing surface, ideally inclined slightly upwards. Her favorite is a fairly expensive model from Levenger's catalog (model BD550) editor's desk ($79). Levenger's also carries other useful (and expensive) items such as weights to hold books open. Call 800-544-0880 or see http://www.Levenger.com.
You can avoid writing quite a bit if you work at it. I was able to do almost all every day activities using speech recognition. Paying bills was one of the few that I had to do by hand. I did a few things to make this easier, including buying return address labels. You may be able to arrange with your electric and phone company to have the bills automatically deducted from your checking account or credit card. You can also overpay bills, saving a month of writing. When I was at my worst, I had a friend do everything but sign the check, but even then, having my friend write fewer checks and not needing to do the return address label made it easier for her.
Try to get somebody to buy better office equipment for you -- ergonomic desks, chairs, typing trays, etc. If your department or employer furnishes you with an office, figure out who it is who buys the furniture, and ask them to buy stuff for you. Or, ask your advisor. Or the department secretary. You probably have a legal right for safe office equipment, suitable for your disabilities. In the Division of Engineering and Applied Sciences, talk to Jean Humber.
Alternative keyboards. If you're not too badly injured, an alternative keyboard may be very helpful (if you are badly injured, e.g. pain at rest, it's probably too soon to start thinking about touching a keyboard at all.) Three of the most common alternative keyboards are the Datahand, the Kinesis, and the Microsoft Natural. http://www.tifaq.org The Typing Injury Archive has much more information than I care to repeat. But here are a few notes. First off, how people respond to ergonomic keyboards tends to be very individual. It's also hard to tell without weeks of experience (and the weirder the keyboard, the more experience is needed.) So, make sure you can try out the keyboard for at least a while before you are stuck with it.
NIOSH (National Institute for Occupational Safety and Health) did a crummy study on alternative keyboards, http://www.cdc.gov/niosh/keyboard.html which concluded they don't make a difference. But there were too many caveats to take the study seriously.
Two keyboards that are worth looking into are the Kinesis, which is reasonably well liked, weird but not too weird, and about $230. The other is the Microsoft Natural Keyboard (and variations), about $40. Some people hate it and some people love it.
Here are my personal feelings about the Datahand, one of the weirdest and most expensive of the keyboards. I tried out a Datahand (The Adaptive Technology Lab ordered one to try out -- if you want to try an alternative keyboard, talk to the ATL, after registering with your school's disability office.) I wasn't able to use it productively. The datahand is very difficult to learn to use, and your hands must be the right size and shape (my pinky was too short.) The data hand is a weird keyboard. When I couldn't use it, I tried to let other people use it: no one was very fond of it. There is however, a good sized group of people who like datahands -- I assume they have the right hand sizes and the "right" injuries.
I've been told that some Windows 95 keyboards make it difficult to hit the control key with your opposite finger, meaning good typing practice is harder. If this is a problem for you, consider using something else.
You might wish to consider a dvorak keyboard layout, especially if you type a lot of straight text. For english text, the dvorak layout reduces finger movement. For programmers, where a lot of time is spent on symbol keys, the advantages are probably reduced. Also, if you spend a lot of time hitting ctrl-key sequences, try modified typing first (use opposie hand to hit ctrl).
Mice. Mice are as much a problem as keyboards for many people. Many people have found trackballs to be a good alternative. A few have liked foot mice (but watch out for ankle tendonitis). Some have liked a stylus on a touch pad. Don't forget to clean your mouse (flip it over; twist off the circle holding the ball in place; remove the mouse ball; scrape the gunk off the rollers inside with your finger nail or a pen or something.) If you switch which hand you use your mouse with, be careful -- you might screw up the other one -- and don't forget to reconfigure your mouse to be left (right) handed, since otherwise you will tend to use your index finger on the left button, unnaturally twisting your hand.
http://www.rsiguard.com is another webpage that has shareware for auto-clicking. RSIGuard also has break-timer features. http://www.savant-software.com has a shareware "RSI Monitor" program that gives you information about how much clicking you're doing and gives you break and stretch reminders. At KnowWareGlobal, you can download (for free) a book which tells you keyboard shortcuts to avoid using the mouse all together.
Consider a head-set phone. Joshua Margolis suggests Hello Direct, a catalogue selling phone equipment, including low budget head-set telephons: 1-800-444-3556. Radio Shack, including the Radio Shack in Harvard Square, also sells headsets.
Buy yourself plastic cups (I found them at Ann and Hope, the Arsenal Mall) for 30 cents each. They may be easier to hold. If you're cooking for yourself or your family, you may want to switch to plastic plates, since they are lighter than china plates.
All sorts of things are bad: shoveling snow, kneading bread, etc. Use a snow blower or a bread machine or hire someone.
The pressure of the mattress on your arms may cause you pain and tingling. (It certainly has for several members of the group.) Consider buying a foam pad for your bed if this is the case; the foam will bother your arms less since it is softer. You can buy a foam pad for around $30 at a foam store; there are several in the Boston area. We have found that the best width for a foam pad is around 2 inches.
Consider an electric toothbrush (a light one); consider an electric razor (a light one.)
Consider putting padding (I use pipe insulation, held on by elastic fabric from Pearl Art and Crafts center) on your steering wheel, to build it up and make it easier to grip. Be careful to do this safely! You don't want it to come off while driving, or to get your hands stuck in the elastic or anything...
Buy sharp knives for cooking. And an electric can opener, maybe. And a non-stick frying pan (who wants to scrub pans with RSI)?
Start your morning with a nice hot water bath for your hands to get the blood flowing.
Use a straw (or even two straws stuck together) in restaurants, so you don't have to lift the glass.
Consider a topical anti-inflammatory, such as Aspercreme, especially if you haven't had success with other anti-inflammatories. But watch out: see the warnings about anti-inflammatories in general, and also, if you had side effects or allergies from other anti-inflammatories, the topical anti-inflammatory may be dangerous: read the warning label carefully.
Keep hands warm, especially while typing (if you can type). I keep a heating pad on my lap, and rests my hands on it during breaks. Consider fingerless gloves (they did nothing for me, but some people like them.) The best deal was the following, taken from the RSI newsletter:
OccuMitts Therapeutic Support Gloves are similar to the well-known Handeze gloves but are less expensive. They come in sizes XS through XL. The suggested retail price is $9.95 per pair, but say you're an RSI Network reader and you'll get them for $4.95 (plus $1 s&h). Call 1-800-466-0071. They'll fax you a size chart if you like.
They seemed identical to me. You can also buy regular cotton gloves. Or, you can buy any pair of gloves, and snip off the fingers. See what works for you.
Watch out for foot problems. People with RSI, especially severe cases, seem at increased risk for foot problems. Wear good shoes, and watch for pain, etc. in your feet. Whether it's because RSIs are often caused by underlying problems which exacerbate problems in the extremities, or because people with RSIs tend to overdo things, or because without hands we use our feet more, I don't know, but be careful.
Buy yourself two new packs. You probably shouldn't be carrying things around in your hands, if you can avoid it. So, you'll need a backpack. Normal backpacks used by students tend to cut into the pectoral muscles, cutting off circulation to the arms, or impinging on the nerves. Instead, you should get a very good pack. There are backpacks available with padded shoulder straps, and thick padded belts, as well as semi-hard (cardboard?) internal backs. These are designed for hikers. They're much less overwhelming than an internal or external frame backpack, but much better for carrying things than a regular pack. You'll need to go to a hiking store to get these. Cost is about $80. The other kind of pack you'll want is a giant fanny pack. These are also available from hiking stores. They come large enough to hold 8.5 x 11 binders, so you can carry a few books in them. Cost is about $40. The two nearest hiking/camping stores I know of are Eastern Mountain Sports, and something across the street from it (Wilderness House?) both on Commonwealth Avenue, in Boston. You might also check out Hilton's Tent City, down town, near North Station (?).
But wearing a backpack can press on nerves in your shoulders or elsewhere and exacerbate problems like thoracic outlet syndrome. Carrying a briefcase can also hurt. One solution is to wear a backpack or book bag around one's waist--you can secure it by tightening the straps around your waist.
Wear your watch on your belt or belt-loop, rather than on your wrist. I've even known someone who said his wedding ring caused problems, and took it off while typing. Or, you can get a nurse's watch, which is on a lapel pin with an upside down dial, from a place called the Vermont Country Store.
Don't be afraid to ask for help. For instance, when my hands were bad enough that any typing at all hurt me, I would ask librarians to type in Hollis searches for me. And to fill out library forms, too. People are pretty sympathetic if you briefly explain your problem.