Repetitive Strain Injury: A Self Treatment Journal

Curing RSI with a placebo... RSI as a placebo?

None of the remedies I've tried have worked for me 100%.  The odd thing is that I've tried very few remedies that haven't worked in some way (at least temporarily).  How can that be?

If my RSI is that susceptible to the placebo effect, could my pain be caused by the placebo effect? 

I ran across this web site while googling "RSI + <some other word>" for the 186th time.  The web site is essentially a flyer for a "mind-body" method for treating RSI, focused on one techies experience.  What struck me about this guy's story was that he claimed to be cured.  He didn't say "under control"  or "almost normal".  He said cured.  And it doesn't look like he's selling anything. 

I read the content of his website very carefully, especially the "three steps" he used to sum up both the condition and the cure:

1. RSI symptoms are due to a lack of blood flow to the arms.
2. In RSI, the autonomic nervous system turns off the blood flow inappropriately.
3. The conscious mind can veto this blood flow strike. (conquerrsi.com)

I tried this method right away.  I turned off the break reminder on my computer and started typing and mousing non-stop.  When my arms started to hurt, I took a deep breath, relaxed, and tried to feel the pulse in my fingers.  Once I could feel a strong pulse, I checked my pain again and it was gone.

Interesting.

Before you do anything because I said it worked for me, read the disclaimer

Obecalp

To fix my repetitive strain injury / tennis elbow, to date I have tried:

• Anti-inflammatories (NSAIDs)
• Physiotherapy
• Massage
• Active Release Therapy
• Trigger Point self treatment
• Omega-3 supplements
• Magnesium supplements & Epsom salt baths
• Vitamin B supplements
• Low red meat diet
• Low dairy diet
• Gluten free diet

Through all this, I cut my pain in half, and allowed myself to function pretty well.  I don't think "functioning pretty well" is good enough.  I want to use my computer whenever I want.  Rationing is not an option. 

I've stopped short of the "aggressive treatments" like cortisone and surgery, for fear that my relatively minor condition could come back worse.  However, I feel like I'm running out of medical options.  There's one drug I haven't tried, and I'm now writing out my own prescription for it: obecalp.  More later.

Nutritional Notes: omega-3

ω−3 fatty acids (commonly spelled omega-3 fatty acids) are a family of polyunsaturated fatty acids which have in common a carbon-carbon double bond in the ω−3 position. (uhhh... I knew that!)

OK, so I have no idea what that means.  As far as I can gather, omega-3 is now the cool kid and omega-6 is passé.  This is the way it breaks down as it relates to RSI:

The omega-6 "arachidonic acid" is converted by the body into a pro-inflammatory agent.  Omega-3 acids compete with omega-6 when being processed by the body, and has the effect of reducing inflammation. 

Why is inflammation bad?  Well (as in most things) it's not bad in moderation, inflammation is what triggers repair when you are injured. When inflammation is out of control chronic pain is the result, a pain that perpetuates itself by limiting circulation, shortening muscles, pinching nerves, resulting in more pain and more inflammation (commonly called the "Pain Cycle").  This theory jives with my experience, because when my pain got out of control, there didn't seem to be anything I could do to stop it from getting worse.

Omega-3 intake is important, but what is more important in the eyes of some nutritionists is the proportion of omega-6 to omega-3.  A proportion of anywhere between 2-1 and 4-1 is considered healthy, depending on who you talk to.  The average north american diet is more like 20-1 or 40-1, which isn't so good.  Such a ratio of Omega-6 to Omega-3 makes us prone to inflammation, and some

Omega-3 seems to make a difference for me, it did before Christmas, When I had some renewed pain.  During Christmas I enjoyed some nearly pain free days while supplementing Omega-3, among other things (Magnesium, Vitamin D, Vitamin C).  I had some problems last week when I took a trip to California and forgot to take my pills for five days, which also backs up the theory.

Before you do anything because I said it worked for me, read the disclaimer

Why do I hurt so much this week?

After a month of what I would consider nearly no pain, my friend RSI is making a comeback.  Starting on Sunday morning (with a bit of a hangover), I have had times when I was in enough pain to drive me away from my computer and keep me away.  What gives?

Finding your RSI triggers amounts to troubleshooting your own body, and it's akin to troubleshooting a computer program.  A very large, painfully complex computer program.  Your output is how much pain you feel and where.  Your inputs are physical activity, diet, medication, ergonomics, stress, attitude, sleep (amount and position), temperature, humidity... there might be a few more.  Things get complicated fast, and it can be hard to figure out why you're in more pain this week than last.

I played World of Warcraft for 2 hours on Saturday afternoon.  It's possible I wasn't paying close enough attention to my pain, and over-worked my arms then.  However, in the month before, I played a little more than 2 hours at a sitting a few times without any lasting effects.  Also, I haven't played since Saturday, and I'm not getting any better.

I haven't been exercising as much as I should (/understatement).  Maybe that's affecting me.  I must say that over the past few months I haven't been very active anyway, so this isn't a recent change.

I drank a bottle of wine with my wife on Saturday night (a cause for minor celebration, as she generally avoids wine).  I can't call myself a heavy drinker, as I have alcohol about once every 6 weeks or so.  Could the alcohol have ruined my entire week?  Can a hangover last a full week?

I started taking magnesium on Monday - could that be it?  Too much magnesium can be a very bad thing, but it doesn't seem likely, unless my kidneys are shot.  Maybe I'm abnormally sensitive to magnesium?  Is that possible?

One thing that happened to me last Thursday might explain it:  most of my success in the past 3 months I attribute to supplementing omega-3.  I ran out of the omega-3 complex I was taking (something like this, a different brand, but you get the idea)  and switched to Salmon Oil.  Not only did I switch to a product with less omega-3, but I went from taking 4 pills a day to 2.  Some quick math comes up with this:

Before - 1600 epa, 800 dha
After - 360 epa, 240 dha

That's a big difference.  I went out and bought a new bottle of stronger omega-3.  Let's see what happens in the next week.

In the end, when troubleshooting a system with so many variables, all you can really do is guess at the causes, adjust your input parameters and observe the results.  Rinse, repeat.

The only other thing I did last weekend when the pain got worse was that I started a blog...

Before you do anything because I said it worked for me, read the disclaimer

Nutritional Notes: Magnesium

Eat some halibut, almonds, soybeans, cashews or spinach and one of the "unsung" minerals you'll receive is magnesium.  Magnesium is used as a laxative and an antacid (think "Milk of Magnesia").  One of the lesser known uses is for relieving muscle pain in treating fibromyalgia or for treating RSI, which is why I've started taking it.  You may have already used Magnesium for muscle pain, if you've ever soaked a body part in epsom salts.

The theory:

"Magnesium and its fellow macronutrient, calcium, act together to help regulate the body's nerve and muscle tone. In many nerve cells, magnesium serves as a chemical gate blocker - as long as there is enough magnesium around, calcium can't rush into the nerve cell and activate the nerve. This gate blocking by magnesium helps keep the nerve relaxed. If our diet provides us with too little magnesium, this gate blocking can fail and the nerve cell can become overactivated. When some nerve cells are overactivated, they can send too many messages to the muscles and cause the muscles to overcontract. This chain of events helps explain how magnesium deficiency can trigger muscle tension, muscle soreness, muscle spasms, muscle cramps, and muscle fatigue." (whfoods.com)

The muscle cramps resulting from not enough magnesium can cause "Trigger Points" (like little knots in the muscle) or even micro-tears in the muscle, which cause pain.  Since I started paying attention in March, the muscles in my forearm and some muscles in my neck and back do seem to be permanently clenched.   I've read about a long term study on tension headache sufferers, showing definite results over 6-12 months (Neurological Sciences).  I've also read about some research into using magnesium for post-operative patients to help manage pain, with mixed results.  Considering that magnesium doesn't seem to do any harm in low doses, "mixed results" are good enough for me.

If you are considering magnesium for your repetitive strain injury or other chronic pain issues, remember this:  magnesium is used in laxatives... Laxatives. That means you should be careful how much you take, or you can wind up afflicted with what my father most delicately calls "the flying axe-handles".

This week, I have started supplementing magnesium.  I've started slowly (for the above reason), with 100mg twice per day.  Daily recommended intake varies from 400 to 600mg.  I will slowly work up to 400mg a day, and stay on it for at least 2 months.  Naturally, I will share my results on this blog.

An interesting read, and one of the places that convince me to give magnesium a shot is a page by Mark London found here.

Before you do anything because I said it worked for me, read the disclaimer

Treatment Options: Physiotherapy

Usage: physical
Approach: Conservative
Description: shock, acupuncture, ultrasound, exercises & stretches...

"Physical therapy (or physiotherapy^[1]) is a healthcare profession concerned with prevention and management of movement disorders occurring throughout the lifespan" (Wikipedia)

 
The definition of physiotherapy is really vague.  The reason is that "physio" covers a whole lot of treatments, and if you see a physiotherapist you will likely get a different set of treatments than I received.  I was given ultrasound, TENS (little shocks), acupuncture, as well as exercises and stretches to do at home.  My physiotherapist was polite and had a really upbeat personality. I think this is pretty important, because when she was "checking my progress" there was some pain involved.

Her professional opinion was that most of my problem was in my neck and not in my arms.  This is the first time I was introduced to a phenomenon called referred pain and to a possible cause of RSI called nerve entrapment (nerve entrapment is exactly what it sounds like, nerves get trapped and squashed somewhere, causing pain further down the line).  She treated my arms with ultrasound, TENS and acupuncture, but half of the exercises she gave me were for my neck and shoulders, rather than my arms.

The variety of treatments was interesting, but it had it's downside.  I don't feel like I'm qualified to grade any of these treatments separately.  Of all of them, I think I would like to try acupuncture again, especially considering my current favourite pain theory: trigger points.  Other than that, i think the exercises really help, and do a lot for correcting my seating position and posture at the computer.

I went to physiotherapy for about 8 weeks.  After the first 3 weeks, my arms were much better, but my progress leveled off.  After 8 weeks, the therapist fired me and sent me to a massage therapist for treatment.  I was a little surprised, as she could have kept me going for a few months more, but I appreciated her desire for me to find the right treatment.  Overall, my physiotherapy worked wonders.  However, like all the treatments that have "worked" for me, the results were not perfect, and I was left to try out the next thing.

Before you do anything because I said it worked for me, read the disclaimer

Treating RSI with a shotgun

In May of 2007, after a first doctor's appointment and 2 weeks of ice, my arms were still getting worse.  It was time to get a family doctor.

Getting a family doctor in Ontario is like getting a part on Broadway.  There's a lot of rejection involved, but it gets easier if you know someone already in the show.  I wanted a different doctor from my wife, so that we could each have a place to get a second opinion.  After a week of phone calls and rejections, I called my wife's family doctor.

She agreed to see me, and once I got into her office, my first productive medical appointment for Repetitive Strain Injury began.  I expressed frustration about my first appointment and recounted the origin of my "Tennis Elbow".  She listened patiently and then recommended a shotgun approach, consisting of these 3 things:

1. Ice - which I was already using.  She recommended even more ice.
2. NSAIDs - she gave me Naprosyn, which helped with immediate pain.
3. Physiotherapy - Physiotherapy proved to be the first treatment to make a real dent in my repetitive strain injury.

My second doctor agreed in most things with the first doctor I visited.  Why did I think this visit was any better than the first?  Because I showed up better informed, because she listened to my concerns, and because she took the time to explain things to me.  Even though another 7 months of pain followed (and persists to this day), I look at this appointment and the accompanying changes at work as the time when my pain stopped getting worse, and when I started my recovery.

Before you do anything because I said it worked for me, read the disclaimer

Treatment Options: NSAIDs

Usage: Oral (Yummy in my tummy)
Approach: Conservative
Description: Tylenol, Aspirin, Aleve...

"Non-steroidal anti-inflammatory drugs, usually abbreviated to NSAIDs, are drugs with analgesic, antipyretic and anti-inflammatory effects - they reduce pain, fever and inflammation. The term "non-steroidal" is used to distinguish these drugs from steroids..." (Wikipedia)

I was prescribed Naproxen twice in the past nine months (Naproxen is most commonly sold by Bayer as "Aleve", the pharmacist gave me Naprosyn, same stuff).  The first prescription was written by my family doctor, the second by a rheumatologist. 

By my first NSAID prescription I knew enough to ask a few more questions and boldly asked if this was a treatment for the symptoms or would it fix my arms.  The doctor replied "Yes".  She patiently explained that reducing the swelling should give my tendons some room to perform repairs, while giving me some short term relief at the same time.  Does this work?  Naproxen alone didn't improve my symptoms long term.  At least, not that I could tell.

A better use for my little Naprosyn pills came later.  I went to see a chiropractor for Active Release Therapy.  He was glad to see me on NSAIDs so that he could really work hard my arms without fear of knocking me out with the pain.

I was on Naproxen off and on for 5 months or so, and there's no doubt that they help with the pain.  I've taken one of these when the pain flared up since, but they didn't cure anything for me.  You can't stay on these things forever, as eventually they will damage something in your body.

A recommendation when using NSAIDs: make sure you get the proper dose.  My rheumatologist scoffed at the prescription I was given by my family doctor (a dosage I had been on for months) and doubled it.   Doubling the dose made a huge difference in the pain I felt while on them.

Before you do anything because I said it worked for me, read the disclaimer

Not just for tennis players...

Tennis Elbow is what my doctor called it.

Tennis elbow is a condition where the outer part of the elbow becomes painful and tender, usually as a result of a specific strain or overuse. (wikipedia)

My elbow started to hurt during what I now call my RSI "perfect storm". 

I was in the final weeks of a year-long project at work.  Naturally there was no time to slow down, as final bug fixes were due and marketing was already plugging the product.  I was both developer and "Technical Lead" for the project, which added the bonus task of worrying a whole lot.  I kept my work fast, intense and stressful, with no health worries, since my elbow only hurt a little.   

I was in the hunt for a little stress relief, which appeared in the form of the uber-addictive World of Warcraft.  Do you hear warning bells?  I do now, but hind-hearing, like the other hind-senses, is 20/20.

For the record, I don't think tennis elbow is now a great diagnosis of my condition.  While tennis elbow was an accurate description of my symptoms at the time, I like the term RSI better (considering the title of my blog, you might have guessed that).  One interesting note is that at the present time, the inside of my elbow hurts more often.  Which it does right now.  Does the inside of your elbow hurt?  Do you play golf?

A first doctor's visit for RSI

I have never been one to visit a doctor unless I feared for my life.

Ontario is a place where family doctors are a rare and precious resource, and I feel guilty taking up their time for anything short of a rapidly spreading infection. 

My first medical appointment for RSI was with a random general care practitioner at a drop-in clinic.  I waited an hour or so, and was seen by a tall and beautiful blonde doctor (I now wonder if her looks affected my opinion of her as a doctor, I hope that I'm more mature than that, but I am a guy after all).  She listened to my story, quickly said "Ice it and you'll be fine, take a Tylenol if you can't stand the pain" and left.

I was expecting a little more, but I was intent to try out her advice.  So, for those of you following along at home, RSI Treatment option 1: Ice, which I tried for 2 weeks before calling my wife's family doctor.

I would give my first doctor's visit a fail.  I'm not giving the doctor I visited a fail, she did her job.  A few months of distance has given me the proper perspective.  She did her job: she saw me, saw no possibility to suspect anything life threatening and sent me on my way with some advice that will work for a mild case of tennis elbow.  She could have confidence that even if the tennis elbow is severe, the ice won't hurt me and I will survive long enough to seek more aggressive treatment.  That's exactly what happened.

Here's my advice if you suspect RSI and you're about to talk to a doctor about it:

1. Study up first.   Do some research on symptoms & causes.
2. Take the results of your studying and compose a list of questions.
3. Go to a family doctor (even if you need to get one first), They know they'll see you again if things don't get better, so they're motivated to take their time to explain everything.
4. Read your list of questions, or just give them the paper.  Medical appointments are stressful and it's easy to forget stuff.
5. Don't scoff at their advice. It's based on years of study and sound medical research.  Your research might have dug up a heap of contempt from frustrated sufferers, but remember: people don't complain when the doctor gets it right, so the average RSI web post can be biased.
6. They'll likely suggest something conservative like ice first.  If you've tried it, let them know.  They may suggest you give it more time, and they could be right.
7. Get a time-frame for follow up.  If your problem is serious, there's a good chance that the first treatment won't work.  Ask them "If this doesn't work, when do I call you again?".

Before you do anything because I said it worked for me, read the disclaimer