most of the popular dictation apps (wispr flow, willow voice) are US companies that stream your voice to their servers and run it through an llm that rewrites what you said. i wanted one that just types what i actually say and never leaves my machine, so we built it.

SpeakUp: on-device dictation for mac, built in berlin. press a hotkey, talk, the words land at your cursor in any app. the speech model runs locally on apple silicon (neural engine plus metal gpu). no account, no cloud, no telemetry. it transcribes faithfully, it does not "improve" your words. paid once, €29, no subscription. eu company, eu payment processor, prices in euros.

mac is live today, windows is in pre-launch and the iphone app is in apple review. getspeakup.app

curious what everyone here is using for dictation right now, and whether the cloud part bothers you or you don't mind it.

Hello, I work at the Accessibility and Academic Success Department at Thomas Jefferson University, and we are seeking feedback on a lower cost dictation application suited for RSI individuals. If anyone is willing to test the app and provide detailed feedback in the comments, I would be able to extend a free month of usage. Just put your notes in the comments, and I will send you a code.

Questions:

1. What is your experience with dictation software?

2. Do you prefer a keyboard shortcut or a foot-pedal for starting dictation?

3. Do you prefer an auto AI cleanup of your dictated text where any obvious errors or corrections are auto cleaned up?

4. How does dictaflow compare to other tools you've used?

5. How does RSI impact your ability to use dictation software?

Download link: DictaFlow | AI Dictation for Windows, Mac, iPhone & Android

Thanks.

Why can you have normal imaging and still have pain?

If you’ve gotten normal diagnostic imaging, ultrasound and nerve conduction studies and your doctor seemed confused about what to do next after a cycle of seeing several other specialists…This thread is for you.

A point in time image does not tell us the “entire picture” when it comes to the cause of your pain and dysfunction. And in many cases imaging results on their own have low overall utility.

In this thread I will help you understand the following

1. What is the purpose of the various types of imaging
2. What can we actually take away from imaging results
3. How your doctors visits and how they discuss imaging results can influence your pain
4. Why you can have normal imaging and still be in lots of pain and dysfunction

Heads up, this is a longer post and is based on the several threads I've done previously all put together to help everyone better understand the context around imaging and chronic RSI recovery.

I'm a Physical Therapist (PT, DPT, OCS, CSCS) and our team has spent the past decade specializing on treating, researching and publishing our work around treating RSI (we've helped more than 3000+ individuals resolve their issues without surgery, more injections, resting, bracing etc. Here is some of our work (we started with the olympians of desk work - esports athletes).

Journal of Orthopedic & Sports Physical Therapy

Tendinopathies in Gaming

Conditioning for Esports (Ch. 8,9,10)

Science of Esports Physical Therapy

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Let’s first talk about what diagnostic imaging & tests are typically ordered for RSI issues at the wrist & hand.

Most typically we hear X-rays, MRIs, & Ultrasounds. Each imaging technique has their benefits in visualizing certain types of tissues. And in many cases we see an overutilization of things like X-rays.

X-Rays: Good for seeing fractures, dislocations, misalignments, and narrowed joint spaces. X-rays can't show soft tissue problems. These are generally ordered since they are more affordable. But honestly many healthcare providers overutilize them.

X-Rays Visualize Bone & Joint Spaces

Magnetic Resonance Imaging (MRI): Good for seeing muscles, ligaments, tendons, organs, and other soft tissues. A majority of our patients seem to have had MRI’s ordered (60% of our patients this year who have been dealing with their problem for > 3 months). There are different techniques that can emphasize different tissues (T1 vs. T2 vs. Proton density imaging).

The contrast between the tissues and the presence of certain coloring (white for example) can indicate if there is water present (suggesting some swelling). Above shows a complete achilles tendon tear.

Ultrasound: Typically the most cost effective option for soft tissue issues, especially if you are trying to visualize more superficial tissues. There are less layers at the wrist & hand so this is often the best option for wrist & hand RSI issues. Ultrasound also providers greater detail compared to an MRI for the more superficial structures. Similarly with ultrasound presence of excess fluid can be indicative of tendon pathology. The image below shows a left and right comparison of a tendon with swelling present and thickening of the tendon.

https://preview.redd.it/t5j8aa0sa99h1.png?width=901&format=png&auto=webp&s=b2b74ad6f7775bcc374bf12181d46fef86dfc590

Nerve Conduction Velocity Tests: These tests are used to assess the function of the nerves in our arms. The Nerve conduction study (NCS) measures how quickly and how strong the signals are as they travel along the nerve. They compare the results with a “healthy nerve” either in the same arm or the other arm. Or they use “normative values” based on age, temperature, limb length, etc. Altered signaling have historically suggested nerve damage or potential compression.

https://preview.redd.it/ahcckkmta99h1.png?width=464&format=png&auto=webp&s=24cabf24e50cf1bca0b416f1746c0325eb3395f8

Now nerve signaling is a bit of a different discussion and there are really important lenses to consider when analyzing the research. Especially as we begin to layer on our understanding of pain science. I’ll share what some of the research says and try to explain why certain situations may occur. And most importantly I’ll help you understand how you can approach your own results. Look out for this in the sections below.

Imaging results on their own have limited clinical significance

All of the current evidence points to the idea that Imaging is best utilized to rule out more serious conditions than “rule in” a specific tissue (in this case a tendon)being the cause of the problem. Basically…they aren’t always necessary.

There are mountains of research over the past two decades that have shown that imaging for not only wrist & hand conditions but issues at the shoulder, neck, back, foot do not provide enough information for a diagnosis.

In this study done in 2016, 19 NONSYMPTOMATIC professional baseball pitchers went through a detailed clinical examination and three MRI’s of their dominant shoulders were taken before contract signing. (2)

• 68% (13/19) of the baseball draft picks showed tendinopathy
• 32% (6/19) had a partial thickness tendon tear of the supraspinatus
• 21% (4/19) had AC joint OA

And many other small lesions were found in the subjects. Yet none of them had any pain.

This was repeated in 634 runners, 3110 individuals for the lower back, and at least 20 other studies including several systematic reviews & meta analyses which have shown that altered tissue states in imaging does not always correlate to pain. (3-5)

I’ll leave some more references at the end of this article. But the research is clear.

What we know is that changes in the tendon tissue can be present with imaging. But BY itself it does not mean anything.

Instead only when you layer on the results of a comprehensive clinical exam taking into all of the details of the patient, patient’s history, activity & behaviors can you really make a decision with the results.

In some cases imaging can make things worse and it is often influenced by your experience with the healthcare provider

How your physician speaks about imaging matters.

With a better understanding about the purpose of each of these tests, let’s explore a key problem about imaging results: How each of these imaging & diagnostic tools are presented towards the patient.

If you’ve ever felt as though you needed imaging to “get an answer” as to what might be going on. There is a reason why and it is associated with the way doctors may be describing imaging in their discussion with their patients.

There is a big difference between

• “The Imaging will tell us what is going on”
• “Lets get some imaging to figure out what’s the problem”
• “I’ll order an MRI and we’ll get some answers” etc.

and

• “well see what we find in the imaging but know that we have to use that information on top of what we know about how your injury behaves to determine the right diagnosis”
• “Ultrasound is an easy way for us to see if there may be some fluid present around your tendon. While this can indicate some damage, it may not mean we have to do something about it. We often have more healthy tissue in damaged tendon tissue. So it be something you can work on to get back the function of your hands”
• “A nerve conduction study is going to be helpful identify how severe any nerve damage might be. It’s important to know the level of severity is NOT a direct measure of the function of the nerve. We’ll have to consider how your symptoms behave with the results of the test to determine the next steps”

It should always be approach #2 but unfortunately due to our healthcare system & how behind many primary care providers are in their recommendations (1), it is almost always #1. How do you think this type of presentation can impact your beliefs on the importance of imaging results?

There are real consequences with how these imaging tests are presented. And it is the responsibility of healthcare providers to provide the nuanced education. But as you have likely already experienced, many do not (it’s not always their fault, the insurance system has some influence on this)

This is WHY we believe imaging results are important. But what does the research say? There are many reasons why pain can worsen after we receive our imaging results with one of them being the altered behavior and beliefs about your pain and injury.

One study found that for work-related acute LBP, MRI within the first month was associated with more than an eightfold increase in risk for surgery and more than a fivefold increase in subsequent total medical costs compared with propensity matched control patients who did not have early MRI. (6)

What we believe about our pain and our experience around the injury can influence what we feel and how sensitive our bodies might feel.

If we believe we are unable to move because we have a “herniated disc” or “disc degeneration” then we tend to move less, perceive that our bodies are fragile and that leads to real physiologic changes that are detrimental to back pain.

If we believe we have to “rest” because our nerve is being compressed through “carpal tunnel syndrome” then we will avoid the activity that is actually beneficial to us.

Imaging is not as useful as we think for orthopedic conditions. For other medical conditions absolutely.

But for musculoskeletal injuries and more specifically those at the wrist & hand associated with tendons? They don’t offer much value as can be shown through all of the research referenced.

Abnormal imaging has been reported in various tendons in as many as 59% of asymptomatic individuals. (7)

Which means that even if they found your tendon to be pathological, it provides no predictive or diagnostic value.

https://preview.redd.it/irk167z2b99h1.png?width=538&format=png&auto=webp&s=66aea2453a76f2c330cc4db7b6c5da20c8f4bdb7

And many cases, when tendons are appropriately loaded through rehabilitation, there is often MORE healthy in the tissue than there is pathological in the tendon. (8)

More healthy tissue when you perform exercises appropriately for the tendon to allow it to positively adapt.

Which means the focus should not be on trying to change the pathology within the tendon, but instead focus on the tolerance to capacity.

All of the tendinopathy research has continued to support this and this has been exactly what we have seen in all of our cases. We only need to focus on

1. Performing endurance-based protocols to improve the tendon tissues capacity
2. Minimize overstressing the tendons
3. Make changes based on how you are responding to the exercises (increased pain & stiffness, etc.)

This again does not mean imaging is useless. It needs to always be placed in the context of the overall clinical picture to help guide decisions. What we have seen is that it is better as a tool for ruling out problems than ruling in.

It can better tell us if there IS NOT a problem than confirming if there is one. What about nerve conduction tests?

Nerve Conduction Tests:

As I mentioned this is a different conversation. Nerve conduction tests actually assess the ability of the nerve to send signaling which means it can accurately identify whether or not the nerve is capable of sending signals at a certain rate. Our experience over the past decade is consistent with what is found in the research in that nerve conduction tests can be helpful but what you do with the results matter.

What the evidence supports is that nerve conduction velocity tests (NCV) are a powerful ADJUNCT to the clinical assessment of nerve conditions. They can help to provide objective confirmation of the pathology of a nerve however they are LIMITED because they do not directly measure “function” and just like imaging always have to be interpreted in context (13).

Research in the past 10 years has found abnormal values within a NCV can be present without any functional deficits or symptoms (14). A study in 2016 performed a NCS on the median and ulnar nerves in 130 healthy individuals with 15% of these individuals demonstrating electrodiagnostic evidence of carpal tunnel syndrome (latency > 0.5ms, borderline mild). The authors cautioned providers AGAINST over-interpreting mild NCV abnormalities to avoid any aggressive interventions like surgery.

Other studies have also shown that the severity of NCV does not correlate with the symptom severity or function. Most importantly studies have supported that NCV cannot reliably predict clinical outcome. (13-17). Many patients with mild NCV changes can experience significant pain, numbness and disability while others with more severe NCV impairment can function better than expected.

Let’s use our clinical experience to provide some context as to why some of these situations have been found in the research (and with our patients).

Situation 1: Mild damage + ⬆️ symptoms & disability

In this situation it is possible that there is mild nerve damage but are contextual and cognitive emotional factors may be influencing pain and as a consequence leading to more symptoms and reduced function. An example we have seen is that the physician informs our patient that the NCV will tell us if we need surgery or not. With mild damage found the physician informs the patient they need to rest to avoid further damage and eventually getting to surgery. This leads to kinesiophobia and fear avoidance behaviors presenting as only being able to use hands for 5 minutes with typing or desk work and feeling 4-5/10 levels of pain. The belief and fear of movement leads to increased disability even though the damage is considered “mild.” Often these patients require some education and proof that they are able to handle more (through graded exposure and confidence in movement through physiologic testing).

Situation 2: More severe damage + less disability

In this situation while there is more severe damage of the nerve the healthcare provider has bene more thoughtful about the approach with the patient and was able to put the damage into the context of the individuals overall pain behavior and ability to still use his / her hands. Despite having more severe damage being shown on the NCV the patient has a better environment leading to less likelihood of sensitivity and consequential disability. There are still limitations due to the nerve damage but the provider works with the patient to understand what is leading to the nerve damage (entrapment somewhere) and is addressing the underlying endurance, postural and behavioral deficits leading to the problem. This is a situation we have seen and have helped individuals restore their function (over a longer timeline) with the right approach.

Situation 3: Mild damage = no symptoms or disability

There are many reasons why this might occur. What we believe to be the most common is the likelihood of a false positive (consistent with research) since the comparison to another nerve in the upper extremity could be unreliable. Or the normative data utilized by the NCS lab may not actually represent the individual creating the “difference” in signaling. This results in mild damage being found as as the studies suggest these results should not be over-interpreted.

Hopefully you can see some of the nuance around how to interpret NCV results. But the most important question is..What do we actually do with the information? To keep it simple it is up to the healthcare provider to identify HOW the nerve is getting irritated. And most of the time, this is barely explored within traditional healthcare environments. For desk workers, gamers, musicians, crafters these are some of the most common reasons why nerve symptoms or irritation may present

• Awkward work / hobby or sleeping postures leading to nerve damage
• Muscle tightness associated with endurance deficits leading to nerve irritation (FCU)
• Transient irritation of the tendons at the wrist & hand leading to some CTS-like symptoms. (underlying problem is still the tendons)
• Entrapment of nerves at the shoulder (TOS).

Why can you still have normal imaging results and no pain?

I'm hoping it is more clear now based on the previous sections why you can have normal imaging results and no pain. But let's make it completely clear.

If your imaging came back clean but you’re still in significant pain, it does not mean the pain is in your head. Your pain is 100% real. Imaging only captures a snapshot of the tissue and CANNOT measure:

• Capacity of your muscles & tendons you use for your specific tasks
• how sensitized your nervous system has become
• how your beliefs and behaviors are influencing your pain experience
• Your lifestyle, environmental and occupational stressors that may influence your pain

And because everyone's situation is different pain may still persist due to sensitization, poor tissue capacity or both. Remember sensitization is the process in which our nervous system becomes more efficient at generating pain signals even when there is no ongoing tissue threat.

https://preview.redd.it/worhhuk6c99h1.png?width=1057&format=png&auto=webp&s=9a2874ddc4e89e3ae12ee4e08578959efbf99ff5

Think of it like a car alarm that’s become too sensitive. The nerves in your wrist and hand become more excitable, your brain’s threat detection becomes amplified, and fear or anxiety around the pain can make the whole system even more reactive. This is a real underlying biological process which can be heavily influenced by your psychology

And again, NONE OF IT SHOWS UP ON AN MRI

Having normal imaging is actually a good sign. It means there is no structural failure requiring surgery. Your focus should be on building the capacity of the involved muscles and tendons through progressive loading, while also working on understanding your pain so your nervous system learns it is safe to move again.

Your body is not broken. It is overprotective. And is something you can work to change

What can you take away from this?

Take your imaging results with a grain of salt. If you have a doctors appointment, make sure there has been a thorough examination that has been performed:

• Physical tests to assess your muscle endurance & capacity of specific muscles you are using
• Clear identification of pain pattern and pain behavior with activity
• Assessment of your lifestyle, daily movement patterns & behaviors that could lead to increased stress on your hand

If your clinician wants imaging make sure the diagnosis provided includes the context of the examination details above.

If it is not taken into account, then you should find a better clinician.

And most importantly…

Understand that for a majority of wrist & hand issues the tendons are involved. The best approach with the evidence we have and the current research on tendon recovery is to manage how much stress is being applied. (load) And for the cases of nerve involvement, understanding how the nerve is getting irritated can ALWAYS be identified with a thorough assessment (posture, ergonomics, endurance deficits, mobility deficits etc.)

Hope this helps

Matt

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References:

1. Ebell MH, Sokol R, Lee A, Simons C, Early J. How good is the evidence to support primary care practice? Evid Based Med. 2017 Jun;22(3):88-92. doi: 10.1136/ebmed-2017-110704. Epub 2017 May 29. PMID: 28554944.
2. Del Grande, Filippo MD, MBA, MHEM*†; Aro, Michael MD*; Jalali Farahani, Sahar MD, MPH*; Cosgarea, Andrew MD‡; Wilckens, John MD‡; Carrino, John A. MD, MPH*. High-Resolution 3-T Magnetic Resonance Imaging of the Shoulder in Nonsymptomatic Professional Baseball Pitcher Draft Picks. Journal of Computer Assisted Tomography 40(1):p 118-125, January/February 2016. | DOI: 10.1097/RCT.0000000000000327
3. Hirschmüller A, Frey V, Konstantinidis L, Baur H, Dickhuth HH, Südkamp NP, Helwig P. Prognostic value of Achilles tendon Doppler sonography in asymptomatic runners. Med Sci Sports Exerc. 2012 Feb;44(2):199-205. doi: 10.1249/MSS.0b013e31822b7318. PMID: 21720278.
4. Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27. PMID: 25430861; PMCID: PMC4464797.
5. McAuliffe S, McCreesh K, Culloty F, Purtill H, O'Sullivan K. Can ultrasound imaging predict the development of Achilles and patellar tendinopathy? A systematic review and meta-analysis. Br J Sports Med. 2016 Dec;50(24):1516-1523. doi: 10.1136/bjsports-2016-096288. Epub 2016 Sep 15. PMID: 27633025.
6. Webster BS, Cifuentes M. Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010 Sep;52(9):900-7. doi: 10.1097/JOM.0b013e3181ef7e53. PMID: 20798647.
7. Docking SI, Ooi CC, Connell D. Tendinopathy: Is Imaging Telling Us the Entire Story? J Orthop Sports Phys Ther. 2015 Nov;45(11):842-52. doi: 10.2519/jospt.2015.5880. Epub 2015 Sep 21. PMID: 26390270.
8. Rudavsky A, Cook J. Physiotherapy management of patellar tendinopathy (jumper's knee). J Physiother. 2014 Sep;60(3):122-9. doi: 10.1016/j.jphys.2014.06.022. Epub 2014 Aug 3. PMID: 25092419.
9. Maffulli, N., Nilsson Helander, K. & Migliorini, F. Tendon appearance at imaging may be altered, but it may not indicate pathology. Knee Surg Sports Traumatol Arthrosc 31, 1625–1628 (2023). https://doi.org/10.1007/s00167-023-07339-6
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Hi. This is my left arm, non dominant arm. I went for a long bike ride one day in April just on pavement, nothing crazy except some hills. I noticed my left wrist felt a little weird during it but didn't think anything of it. Shortly after that, my arm started hurting in these two spots when I lifted heavy things like my water bottle. I'm in physical therapy for lower back pain so I mentioned it and my PT told me to just rub the spots because it sounded like golfers or tennis elbow. Rubbing the spot near my elbow is okay, but the lower spot hurts too much and doesn't feel right to be rubbing that hard. My arm hurts A LOT while I'm sleeping. I even slept with it wrapped in a towel one night to limit bending, but I still woke up in pain. It hurts to twist my arm both ways. I work from home at a desk but honestly I take enough breaks throughout the day that I'm not sure it's the cause. Any advice or exercises I can try?