Why You Don't Need to Change Jobs with Chronic Wrist & Hand RSI
Have you thought about changing your career due to your persistent wrist & hand pain? Did you have this thought after several visits with your primary care or specialist who mentioned you might have to work less or think about changing your career?
Or was it after reading doomer posts within communities suggesting that might be the “best” option. To “stop doing” the things that you previously did not have issues doing.
What if I told you that you NEVER have to change your career in response to RSI, no matter how chronic.
It is easy to understand how some might reach this conclusion based on their own experiences and what they're told by their healthcare providers. And how any framework that might challenge that belief would be difficult to process.
However over the past 11 years we have worked with (3000+), 0 individuals have had to change jobs due to their pain. Even issues as long as 16 years. Even with surgeries that didn’t help. Or when the doctor suggests surgery is the only next option without any promises of how that will actually help you use your hands more again.
EVERY RSI can be resolved. It is just a matter of actually addressing the underlying issues… and time. Patience to address your specific combination of physiologic, cognitive emotional, environmental, lifestyle and other factors.
If you ONLY avoid movement, rest more, find another brace, take more medication… have you ever wondered how that will actually improve your ability to use your hands more?
How do you think that will help your tissues handle more stress? After the “inflammation” goes down, does the resting make them stronger? Do your tendons supercompensate in response to no stress and allow you to handle more? (No & No).
And do your work demands change while you lose more of this capacity while going through these rest and passive treatment cycles? Or does it stay the same leading to more risk of irritation.
Just reflect a bit while I try to provide a more nuanced understanding of how to approach improving your ability to handle work-related tasks with less overall pain. I’ve written about this before but everyone’s “pie chart” of what is contributing to their current levels of pain and pain experience will differ.
The pie chart is influenced by:
- Physical conditioning (based on the level of activity, exercises and your overall lifestyle during and before your injury). You can think of this as the actual physiologic deficits. You might have some endurance deficits from many years of inactivity. Or the when the injury started you did too much, too quick, too soon (10-12 hrs of activity several days in a row). There are many possible reasons why your muscles & tendons could have been irritated in the first place. Then with repeated healthcare visits following passive interventions the tissues weaken. This puts you at MORE risk of irritation upon return to activity. Pain may be gone but capacity is reduced.
- Mental Drivers then can play a role in the sensitivity of your pain. You can feel more pain despite your tissues being safe. The chronicity leads to real changes in your nervous system that causes it to send more signals to your brain, leading to this increase in pain. On top of this fears, reduced self-efficacy, anxiety around your work all influenced by what you are told from your providers or what you read online can further sensitize your pain. This is not “just in your head” but real cognitive habits and responses to pain that lead to real changes in your nervous and immune system.
3. Your environment can also play a large role in your pain. This may not be surprising for some but your job stress, perception of heavy work or occupational demands and attitudes of those around you can all directly influence your pain as well. If you are constantly provided with subtle cues from your family and friends that you “need help” or are unable to perform certain tasks that can affect your self-efficacy and illness perception. If you have high stress at work it may influence your immune system to send more overall signals and increase your pain during specific tasks.
Now just because all of these things CAN occur it does not mean it will. But the reason why share this comprehensive approach so often is because all of these factors must be assessed AND addressed if you want to fully recover (not only that but change your relationship to pain).
We’ve zoomed out to hopefully put your current status into context. You dont’ need another brace. You don’t need to make a subtle change to your ergonomics to reduce stress per unit time right now. You need to actually understand what is at the root of your pain and limitation in function. It is ALWAYS a combination of your physical and mental factors. Your hands are always there, yes but your brain is ALSO always there there which means it will always play a role. In some cases it doesn’t play as large of a role (typically earlier in the injury timeline, less overall doctors, less of an obsessive personality). So let’s now talk about some ways you can get back to using your hands more with work.
Cause of Repetitive Strain Activities with Desk Work
First off.. what’s causing your pain with desk work or repetitive activities?
We use our wrist & hands to perform the repetitive actions of typing, clicking, mouse movement in front of a desk. What controls those movements? Muscles & Tendons
Muscles originate at a specific part of the body and then insert onto tendons (which connect muscle to bone). Our bodies use this to repeatedly perform certain actions. And based on the specific type of action it will require that those muscles have a certain amount of endurance or CAPACITY to handle it.
Now if you don’t have enough capacity to handle the repeated stress that you are placing on it over your work session… they can get irritated.
When we’re younger we have alot more endurance and capacity. But over many years of physical inactivity and repeated use of the wrist & hands for many hours… would you expect your muscles & tendons to
A: Have more capacity to handle stress? (Strengthen!)
B: No change - Maintain its overall capacity
C: Reduce its capacity to handle stress (deconditioning)
I hope most of you came to the answer of C. Cause yes while it is possible to have SLIGHT increases in capacity due to small repetitive stress of the wrist & hand. It’s not enough actual LOAD on the tendons or muscles to improve its actual capacity in a meaningful way.
Think like if you were performing bicep curls for an avg bodyweight of 150 lbs
- At 1 lb bicep curls you’d have to do 100s to improve your endurance
- At 15 lbs you’d probably have to 15-20 to achieve some improvements in size, strength and endurance.
We need to load them appropriately with regular exercise to build its endurance to handle enough stress. Let’s use the example of an.. ELEVATOR. Let’s say the weight capacity of a small elevator is 1000 lbs
4 People walk into elevator, each of them weighing 200 lbs (800 lbs total), Then a 300 lbs individual walks in and causes one of the cables holding up the elevator to be strained
The elevator cables get some strain and put the individuals inside at risk for some harm if it continues! Just like the cables of the elevator your muscles and tendons only have a certain amount they can handle too.
With an elevator running at 95% and sometimes more than capacity every day, it can really wear down those cables. When we repeatedly expose our wrist & hand to stress from typing, drawing, gaming, playing guitar
It can strain our tendons (and muscles) But only if we don’t have enough “capacity” it can cause irritation and pain. You can improve the capacity of an elevator by “strengthening” the cables. Or even adding more cables
You can improve the capacity of your tendons by performing endurance exercises. If you never maintain the elevator cables, they can rust, fray and weaken. This is similar to tendons becoming deconditioning from inactivity or prolonged underuse
So do exercises consistently so you can keep your muscles & tendons healthy, fix your pain and keep doing what you love
And hopefully this helps you understand that the SOURCE of the pain is likely your muscles & tendons But the CAUSE is most typically
- Poor Endurance
- Posture & Ergonomics contributing to increased stress per unit time on those specific muscles (learn more about this here)
- Lifestyle & Scheduling. If you work without any breaks and high volumes it can lead to you straining your wrist & hand more quickly than those who take more breaks and regularly stretch.
- Poor Understanding of pain
So… clearly to address this problem we have to target one of the four right? Yes. Let’s go over a stepwise approach you can take to start using your hands more with less fear that it will cause you to need to “change careers”
How to actually still work while focusing on recovery
Here is a 3-step approach you can take to keep your job and use your hands more confidently.
Step 1: Establish your baseline
It is important to understand your current level of physical conditioning, activity tolerance and current understanding of pain to determine the right strategy to improve your capacity to work with less discomfort. You can honestly save time by finding a good physical therapist who understands pain to do all of this!
We’ll start with the physical aspect (endurance + activity tolerance). The best way to think about this is establishing your specific and general endurance.
General endurance involves the endurance of your muscles & tendons as measured through your ability to perform exercises to failure. Specific endurance is the endurance of your muscles and tendons in response to your real-world activities.
Why Both Matter: General endurance gives you the physical foundation, but specific endurance teaches your body to apply that endurance efficiently in real activities.
To establish your general endurance you can select a light weight (2-3% of your bodyweight) and perform an exercise for your specific muscle (flexors, extensors, radial deviators, thumb extensors etc.) until fatigue. Ideally you want to work with a physical therapist to establish this. You can always figure things out on your own, but it will take much longer.
Use the amount of reps you can perform as a measure of your overall general endurance. This is the number you want to increase over time. We have found from performing our specific endurance test protocol (specific movements, cadence & bodyweight, data collected from over 3000 individuals) for those who are able to handle 3% of your bodyweight for a certain amount of repetitions typically equates to being able to handle a full work day (repetitive activity of desk work) for 8 hours without risk of tissue irritation or pain.
Now for specific endurance you have to establish exactly HOW you are working, how the pain is behaving, how irritable your condition is. These are typically things you establish when working with a Physical Therapist. There are things like
- How long are you typically working?
- How many breaks do you take?
- How long can you work before you have to take a break?
- What is your pain once you get to that point?
- How quickly does the pain come down after your break?
- What strategies do you use to still achieve your work tasks while minimizing physical stress on your hands? (Swapping Input Devices, Voice control, etc.)
So for example this would be
I work from 8-5:00 PM. My first work session is 8:00-12:00 PM before lunch. But during that period my work is distributed as such due to my pain
- After 1 hour of work my pain is at 4-5/10, then I take a 30 minute break. Pain goes down to 1-2/10
- I have to finish work so I finish up another hour. Pain gets worse (5-6/10) so I take another break at 1 hour, goes down to 2-3/10.
- I swap to voice control or L. hand during this time to ensure I can still finish up the rest of the block
- I rest, heat, massage and relax during lunch to allow myself to recover
- I repeat the initial work block distribution. End of work I feel 4-5/10 and it takes 2 hours to go away
Once you have this baseline you can make intentional changes to deload your wrist & hand while you are focusing on building your capacity but ALSO still accomplish the tasks you need at work. What you are feeling can also directly impact what you think you can “tolerate.” Which is why it is also important to establish a baseline of how much sensitization may be influencing your issue.
There are validated questionnaires which help to indicate if anxiety, fear-avoidance, cognitive habits are contributing to your chronicity or sensitization of pain. You can get access to them here for free.
Fear-Avoidance Belief Questionnaire (FABQ) - focuses specifically on how a patient’s fear-avoidance beliefs about physical activity and work may affect and contribute to his/her pain (i.e. the cognitive/affective components of pain that are differentiated from specific tissue damage, injury, and nociception) and resulting disability. Click on “instrument details” to get the pdf of the questionnaire and score yourself!
Fear Avoidance Component Scale - The Fear-Avoidance Components Scale (FACS) is a new patient-reported measure designed to comprehensively evaluate FA in patients with painful medical conditions. It combines important components of FA found in prior FA scales, while trying to correct some of their deficiencies, within a framework of the most current FA model. Get access to it here
Pain Catastrophizing Scale - For many who have really struggled with chronic issues, this approach might be ignored since it might not fit their current mental model of their injury status. ButI’d really encourage you to be open to goign through these validated questionnaires.
Pain catastrophizing is characterized by the tendency to magnify the threat value of a pain stimulus and to feel helpless in the presence of pain, as well as by a relative inability to prevent or inhibit pain-related thoughts in anticipation of, during, or following a painful event. (Might sound familiar if you read a few of the posts / comments in the subreddit) The PCS was developed to help quantify an individual's pain experience, asking about how they feel and what they think about when they are in pain.
Completion of these questionnaires will likely be revealing in understanding that you may have some cognitive habits, fears, behaviors and anxieties that can lead to real consequences in how your pain behaves. And understanding this is often the first step to making some progress towards recovery. You can learn more in either our posts or all of the research out there on pain science (Explain Pain Handbook, The Way Out, Tame the Beast website, Sarno’s Work, Dan Buglio, etc.)
This leads to step 2, Early Loading, Modifying Activity & Integrating Pain Understanding
Step 2: Early Loading, Modifying Activity & Understanding Pain
The next step is to use the data you have collected to perform your loading and graded exposure program. Again work with a Physical Therapist to establish what this program looks like (it has to target the specific tissue involved with your region of pain). Ideally this physical therapist can direct you towards helpful resources to understand pain and put it into the context of your specific situation.
Based on their understanding of your current schedule they can help you implement an activity plan that matches your capacity but also does not push you towards elevated symptoms without need. Using the example above, here is a way you can use the activity tolerance data to make decisions about how to modify:
On the first work block if you know you will reach a 4-5/10 after about an hour you can intentionally take a break at 45 minutes. And from there take the same 15-30 minute break. During the next session you can intentionally use a different input device (voice, L hand mouse, roller mouse, trackball) utilizing different muscle groups to complete the second block and provide yourself relative rest.
Then you can repeat this 2 hour block for the second half of the AM work block and repeat for the PM work block.
EVERYONE is different but most people figure out what works best for them very quickly. Expectedly since you need to maintain a certain level of productivity at work. Progression should follow tissue adaptation timelines depending on your problem and the guidance of your physio.
And as you might expect there will be times that are challenging. Why? because work is never the same day in and day out. You may need to finish a work sprint, complete a project deadline, submit a report etc. Additionally adaptations in your nervous system (central sensitization) may lead to the situation in which you feel an increase in symptoms despite tissues being completely fine.
This requires collaborating with your physical therapist to understand how this might occur based on your specific history, beliefs, understanding of pain and fear. When we have been consistently exposed to situations in which pain is elevated during a meaningful activity our body often uses this as a filter to create the experience of pain (sensitization). And again this is not just “in your head” but is mediated through REAL changes in your nervous and immune system.
If you do not understand why you can safely continue with your activities despite feeling an elevation of symptoms, it makes it difficult to make decisions about what you can or can’t do during recovery.
This is why flare-up management and processing pain is a crucial part of recovery. Which is step 3
Step 3: Responding to Flare-Ups & Return to Function
During these situations of elevated symptoms it is important to remember to be patient.
Patient because it takes time for tissues to adapt and if you are managing it on your own learning how to be intentional about your schedule and track things can be difficult. Additionally it also takes time to change your understanding of pain and integrate that into your day to day experiences while also improving your overall capacity. (Being able to recognize what variables may be leading to sensitization and still safely continuing activity at certain levels of symptoms understanding it will help create more safety signaling over time). I discuss how this works in more detail in this article here
The goal with step 3 is to better manage situations in which you have elevated symptoms (flare-ups), gradually increase your activity to show yourself you can handle more safely and build capacity while learning what variables may lead to these changes in symptoms.
I’ve wrote a full guide for this which you can follow. But the TL:DR is that there is always going to be a reason why you have increased pain. It can either be explained by some level of physical stress (cognitive emotional for people outside of this profile).
Your ability to determine what leads to increases in pain AND how to appropriately respond to them will directly correlate with how quickly you recover.
I truly hope this provides some help to you if you fall into this situation! If you have questions let me know 😄
-Matt
