GENERAL TIPS ON FINDING CARE FOR RSI
These are excerpted comments on practitioners in general:
these are OPINIONS gleaned from the SOREHAND e-mail
list and other Internet sources, not my own.
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I am an occupational therapist who specializes in treatment of the hand,
and I have also suffered from Carpal tunnel sydrome. I think that before
you take any medical advice over cyberspace, perhaps you should see (1) a
hand surgeon, and (2) a hand therapist. Proper diagnosis depends on many
factors, to include a history, an exam, neurological tests, and others. As
they vary for person to person, each must be properly considered. After
proper diagnosis, your physician may send you to a hand therapist, who can
hopefully help. Be advised -- the news media and medical literature are
overflowing with a lot of confused information on this condition. That's
why you need a trained guide.
There is no good "rule of thumb" that can be used to find a
good health practitioner when it comes to CTD's. At least
not any one that I can figure out.
There is a diverse set of individuals, such as Hellerworkers,
Massage Therapists, Physical Therapists, Surgeons, Physiatrists,
Orthopedic Surgeons, Chiropractors, Feldenkrais and Alexander
Practitioners, Plastic Surgeons, Osteopaths and who knows
who else, that all have had success in treating patients. The
problem is, that for each successful practitioner, there are
a number of unsuccessful practitioners WITHIN THE SAME AREA
OF PRACTICE. So we can't make a blanket statement such as,
"You need to see a physiatrist (or whatever) in order to
get good treatment" because there are "good" and "bad"
physiatrists. Couple that with the fact that, in my opinion,
no one practitioner has all of the answers (i.e., near 100%
success rate) and you can see where some of the discouragement
My advice for someone looking for treatment is this: Get as
much of an education as you can before seeing someone for
treatment. Then you will be better able to determine, in
1 or 2 visits (or perhaps over the phone, if you are
lucky), whether or not this person has any answers for you.
Be ready to be scorned by medical practitioners who either
(1) know less than you or (2) are perplexed because they
don't have any answers to your questions. At least you
will know right away not to book a followup appointment :-)
Also I would suggest these folks seek speciality
care whenever possible. An orthopedic specialist is not necessarily a
specialist in CTD. Also it's important to find out up front the number of
cases with a similiar diagnosis the physician sees each year. Sometimes a
good way to find a doctor is to call a nurse paractioner in the area or to
call your local rehab unit and ask the director of OT or PT to recommend a
doctor who treats patients with a particular diagnosis. I'm afraid I don't
have many other suggestions.
Karen Schneider, OTR, CHT
RSI Moderated Panel Member
Directory of Medical Specialties at your library. It is a national
directory and lists by specialty. Included is the MD's educational
qualifications, year(s) and location(s) of same, and their
addresses/hospital affiliations. It's a good resource for checking
background. Also ask about board certification, when interviewing MD
and, in our cases, never forget to ask about RSI knowledge/experience.
It's worth your time and $ to get the book:
Repetitive Strain Injury: A Computer User's Guide
Dr. Emil Pascarelli & Deborah Quilter
It will do much to give you info you need to make an intelligent choice
of doctors and has specific advice on finding care.
I've seen several messages over time about experiences with doctors
regarding repetitive stress injuries. My experience is that the best type of
Dr. is a specialist in Physical Rehabilitation medicine. These types of
doctors are used to dealing with muscles, tendons and connective
tissues--that's their specialty.
Look for a good physiatrist or hand surgeon for evaluation. As far as
therapists go, try to find a Physical or Occupational Therapist with the CHT
(Certified Hand Specialist) designation. I think you'll find
private-practice settings more personal and responsive than corporate- or
hospital-owned. Not always true, but . . .
Have you tried seeing a physiatrist (md of physical medicine). They are
much better than most hand md's & orthos in txing RSI. I work w/ workers
comp as an RN case manager and have found the physiatrist to be better at
diagnosing and informing the claims examiners about how one area of
injury causes guarding and this results in pain in other areas.
A physiatrist (pronounced fizz ee at' trist) is a doctor that specializes
in the physical medicine and rehabilitation (non-surgically) of patients.
Many people are unaware that there is a special branch of medicine
specifically dedicated to the diagnosis and treatment of physical
disability. Physiatrists are doctors who are certified as specialists in
rehabilitation medicine by the American oard of Physical Medicine and
Rehabilitation. The area of medicine they practice is called "physiatry."
Physical Medicine and Rehabilitation (PM&R) was born in
1946 in response to the hallenge to help disabled citizens reach their
maximum potential. What is so special about these specialists? After
completing medical school and obtaining an MD or DO degree, they study four
more years and take two extra examinations, one written and one oral. The
purpose of this extra training is to make sure that physiatrists are
focused on the patient as a whole person. Most physicians deal with illness
and possible threats to life. The physiatrist deals with functional loss
and threats to living fully -- the physical and psychological disabilities
remaining after initial medical or surgical treatment.
The physiatrist often coordinates a team of other doctors
and health professionals in developing and carrying out a comprehensive
rehabilitation plan which extends beyond hospital walls into the patient's
family, community, occupation, friends, and utimate life style. This
rehabilitation team may include physical, occupational, and/or speech
therapies, nurses and doctors from various specialties, including
neurology and orthopedics, psychologists, counselors or social
workers, rehabilitation engineers and others.
The physiatrist's success comes through a team effort
where the patient is an itegral part of the team process. Each improvement
in function, however subtle, can significantly improve the life of a patient.
A physiatrist specializes in injury recovery in therapy and is most
likely to be more knowledgeable about repetitive stress injuries than
most surgeons. Out of eight doctors that I saw only one was really very
knowledgeable and he happened to be a neurosurgeon. I found that most
surgeons hand or orthopedic were not very helpful. The hand surgeon I
saw was the worst, once he discovered I was not a surgery candidate he
basically told me to go find a new doctor.
Your surgeon can write a prescription for other types of care. In the case
of massage therapists, they do not need authorization by your
w.c.adjustors, P.T.s, and other M.D.s, only the prescription. I have
treated many clients in this fashion.
> [Original Message]
> Date: 9/27/03 8:44:50 AM
> I agree that I may find more help outside conventional medicine. However,
> the California WC fiasco I have found myself in leaves little room for any
> alternatives. While I would love to seek the remedies that Keith has
> am not able to foot the bill myself for such treatment. Thus, I am left
> the hands of my "normal" surgeon.
There are more and more performing arts medicine centers forming, and
musicians' injuries are often very similar to typing RSIs. So you might
see if nearby hospitals or medical centers have such a center.
I find that many people who are successfully recovering from RSI report
a major factor is "physical re-education", or learning to use the body
in non-stressful ways. Some leading methods to do this are: the Feldenkrais
Method, the Alexander Technique, Tai Chi, and others. Look for local
practitioners of these disciplines . . . BUT I still say SEE A DOCTOR FIRST
for evaluation, because RSI can involve so many different factors.
I've been really picky about my doctors in the years since I first started
getting help for my RSI (in late 1992) I have had good luck by calling the
doctors and asking the nurse or receptionist if the dr is patient and listens
to you, or if the dr just listens for a little while then tries to treat you.
I have found several folks who will tell me ON THE PHONE that the dr is one
of the brusque types, so I can stay away.
So folks, I recommend that you SHOP for your doctor, and make it clear on the
phone that you are doing so. It will be hard at first, and confusing, but it
is worth it. BTW, I just shopped for a therapist and all the places I called
were willing to talk to me over the phone for extended periods (more than
half an hour in one case) to understand my problem. Some of them even turned
me away and recommended someone else. So be polite but firm, and ask for
what you want. And remember, even in the ins co is paying, YOU are hiring
the doctor, the dr is not doing you a favor by treating you! Would you take
this kind of abuse from your landscaper? Your cleaning service? A clerk in
a clothing store?
> And get a second opinion if at all possible. And for goodness' sakes, make
> sure it is a HAND/UPPER EXTREMITY SPECIALIST!
and make sure this specialist will take the time to thoroughly
examine you and not just briefly look at your hands/wrists and call
your problem "non-specific." before finding a TOS specialist, my
previous doc (a hand surgeon) spent about 1.5 hrs examining me and
taking my history. i asked in advance if he would be willing to listen
to my concerns and answer my questions.
that's b/c my FIRST hand surgeon (very well known) looked at my thumbs
& wrists (orig. symptoms) and refused to look upwards even when i told
him that my forearms and elbows were in immense pain ("doesn't
matter," he said), that my arms were falling asleep, and that one of
my arms had strong pain creeping up my arm to my shoulder (he said it
couldn't possibly be related and spent 8 min. w/me, 3 of them on
small-talk). he pronounced that he could find no nerve entrapments
and that if i did not heal in 6 wks he would recommend changing my
career. i felt as low as could be after that visit and finding the
next hand surgeon helped a lot.
get dr. recommendations!
California Labor Code Section 4600 under the term "physician";
Acupuncturist are included in the term and are approved to treat industrial
injuries. An acupuncturist must hold a certificate issued per Business and
Professions Code section 4925 et seq. This authorization is effective until Jan 1.
1997. However acupuncturists are not authorized to determine the extent of
Cite: CA Workers Handboook, 13 edition by Herlick
speaking to my accupuncturist about other physical ailments, I was told
that accupuncture is often waht is needed to lift any pain you have, but
in some cases it will not work as a curative agent. It will however take
away the pain, and give you some use back until you can do something else
for the problem.
For me, accupuncture was inexpensive (hip hip hooray, because I was a
student at the time) painless and VERY effective. My experience with
accupuncturists is that they know their limits and will tell you if you
have a problem that they can't help you with (unlike some other members
of the medical profession ou there) so if you can just make an
appointment to go speak to someone, I believe you'll get some sound advice.
Many people have tried acupuncture but because it is an unregulated
profession in Ontario, people don't always get the results that they expect.
Many practitioners of acupuncture have only had a few hundred hours of
training...or less. My advice to all who seek acupuncture is to see a
trusted, qualified practitioner that has had at least 1500-2000 hours of
training as well as adequate clinical experience. It is also very important
to ask about the needles used by the practitioner. Recently, some people
have been discovered re-using needles that have not been properly cleaned.
This should never happen. To be on the safe side, go to a practitioner that
only uses stainless steel, disposable needles. To graduate successfully
from my TCM college, I had to pass a Clean Needle Technique (CNT) exam that
is outlined by the National Acupuncture Foundation in the US. It is the
same exam that all US practitioners are required to pass before they are
allowed to practice in the states. It is currently not required in
Ontario, but in my opinion, it is an extremely important thing to experience
as a practitioner.
I have tried acupuncture sessions since then, and have found them to
be somewhat relieving, and refreshing, but by no means nothing nearly
as dramatic. Here are my takes on this:
1. I think practitioner skill varies extremely widely. I now try to
look for practitioners that are confident they can accomplish
something in 3 - 5 treatements and seem to be approaching acupuncture
with an analytic mindset.
2. I find that acupuncture gets regarded as a cure-all all too
frequently. I don't think it is. I think it is highly effective for
chronic musculoskeletal pain, and a handful of other things, but I try
to stay away from anyone who bills acupuncture as a cure-all.
3. I personally found that acupuncture made the most sense to me as an
intervention: it provided dramatic relief from muscular pain and
tension, and gave me a few hour window of extremely strong nbody
awareness to play wih patterning my body in. I think acupuncture would
have been, in the long-term, ineffective had I not been focusing on
the habit of poture. I think acupuncture was for me an extremely
useful accelerant to reshaping rthe habit of how I used my body ...
but I think on its own, it would have not ben effective at reshaping
the core habits causing my neck pain.
So I thinkmy general advice is talk to a lot of different
ractitioners. Find one that seems thoughtful and confident in what
they do. If you're really curious, it doesn't hurt to do some reading
on your own -- the classic intro texts to chinese medicine that I know
of are Ted Kaptchuk's "The Web That Has No Weaver" and Efrem and
Gold's "Between Heaven and Earth." Reading the first chapter or two of
either of those will gaive oyou the beginnings of a common ground to
evaluate acupuncturists on.
There is no one type of medical practitioner that has an edge over another,
for the most part. It seems to depend directly on their interest and
experience in treading CTDs.
If you call and ask if they treat TOS or CTS or RSI (choose your buzzword),
they are likely to say "Oh, yes, of course!" when in fact they
have only heard these terms used on the local news channel.
One thing to do is learn as much as you can as fast as you can, then talk to
them in general terms. Ask them open ended questions and see how they respond.
You don't have to know the answer beforehand, and you may not know the
answer, but you should have enough familiarity with the topic that you will
know whether or not this person even has a clue.
For example, if you are suffering from chronic myofascial trigger points, ask
what s/he thinks about Travell's thoughts and practices of treating muscle pain.
(Hint: Don't say trigger points). If s/he does not know who Travell is or does
not know about her treatments (and does not mention TP's) then that is a pretty
good clue that you need to look elsewhere. Similarly, if you are seeking TOS
treatment, ask about Roos'. Though he is only one of many, he has done a lot
with TOS (rib resections, that is). If s/he does not know Roos, then ask whose
protocol s/he follows in treating TOS. Perhaps s/he may tell you that it is
his/her own. Well, that may be good, but I would be skeptical.
If you have a family doctor, consider educating him/her on this topic. Pass on
journal articles, etc. Then ask this person to make some calls and do the
screening for you. Peer to peer, the doctors talk differently, and you may be
able to get some better information. Might even ask to be put on the speakerphone :-)
The bottom line is, without a good referral, you are going to have to do the
screening. Otherwise, get ready to dump a lot of money into a black hole.
I am an occupational physician. I have not seen you in consultation, nor
have I examined you. Therefore, my advice to you is generic, and may not
apply to you. However, I see many cases of upper extremity pain, and have
considerable experience with it ( . . . ) chiropractors are generally safe
therapists if they use standard precautions. For many kinds of upper
extremity pain for which surgery is not suggested, both standard physical
therapy and chiropractors have about the same rate of success, and the
outcome is quite variable in the hands of both kinds of practitioners.
Personally, at the present time, I prefer to send my patients to physical
therapists who have been trained and certified (and I mean CERTIFIED) in the
McKenzie technique of evaluation and treatment. They are not in every city
by a long shot. You will have to call the McKenzie Institute, or one of its
satellites, to get the McKenzie-certified therapist nearest to you. I know
there is such a place in Syracuse, New York - the spine center which is
affiliated, I believe, with the medical school there. Call them to find the
nearest McKenzie therapist if you are interested in that approach.
Some chiropractors adjust the bones in your hand, in addition to those
in your spine. Often many adjustments are done, and many patients find
they must continually return for adjustments -- when a bone ``goes out''.
Forceful movements of bones may stretch ligaments and soft tissue, so that
the bone no longer stays where it should, but tends to wobbble -- thus
the revolving door effect. I expect this is especially true of the small
bones in the hand.
Therefore, I recommend chiroproactors that use gentle adjustment techniques,
such as non-force technique, move the bones by working on their associated
soft tissue, and/or give you exercises to strengthen and balance the
tissues that hold bones in place.
If a spinal or hand bone is in the wrong position, and there was no
tramatic injury -- there is a reasons. Like CTS surgery, correcting the
effect will not help long unless the cause is addressed.
As far as Chiropractors go, please check out there credentials first, as with
any physician, there are good ones and bad ones.
The good ones will have post graduate certificate and diplomates, along with
plenty of continuing ed credits.
For the past year I have been seeing various chiropractors and out of my
personal experience I am now a student at a chiropractic college in San
Jose, Ca. At first I didn't think a chiropractor could help with RSI or
considered musculartendonous involvement. A good chiropractor works
with remodeling the whole body. This includes active release therapy,
proprioceptive neuromuscular facilitation, isometric and tubing
exercises, weights, stretching, adjustments, and more. I have found
that it is relatively inexpensive since I didn't have insurance and
could not afford to go to a physical therapist.
It is probable that chiropractic can help you maximize your healing
potential. That's what chiropractic does - it increases your body's healing
capabilities. We do this by adjusting (manipulating) your spine and extremity
joints. I am in my tenth year of chiropractic practice, and have not found
one person with CTS who has not had problems in the neck and upper back. By
"problems" I mean this: a) spinal subluxations (misalignments) that leads to
nerve compression, loss of joint motion, and accelerated degeneration, b)
myofascial components involving the entire upper extremity - not just the area
around the wrist, c) misalignments of the joints of the wrist, and possibly
the elbow and shoulder.
When you visit a doctor of chiropractic's office, he/she will evaluate your
carpal tunnel syndrome in a number of ways (depending upon the doctor - but
that's too involved to get into right now). A chiropractor knowledgeable
about RSIs will first take a complete history of your condition, including
past problems or injuries to the neck, shoulder, arm, etc., and also
investigate arm/wrist use in your profession and hobbies.
Once this information is gathered, he/she will evaluate your spinal health by
feeling (palpating) along the spinal column. We check for subluxations which
are misalignments of the spine. The subluxation complex leads to a number of
events - a localized inflammatory process, nerve irritation, loss of normal
range of motion, localized muscle spasm, and degenerative processes to the
Next, we will evaluate the muscular health of your upper extremities.
Palpation of the muscles, tendons, and bones of the upper extremity is
performed, checking for irritation, spasticity, loss of range of motion, and
myofascial trigger points.
Some orthopedic testing may be performed, depending upon the type of problem
you are experiencing. Neurological tests help to determine the extent of
Most chiropractors will take x-rays of the neck, upper back, and possibly the
wrist in CTS cases to help determine the extent of spinal involvement. All
this information gathered is put together in your "report of findings" and you
will learn whether or not chiropractic can help your condition.
A good treatment protocol for your recovery should implement chiropractic
adjustments, nutritional counseling, rehabilitation protocols, and myofascial
I hope this helps you decide on your future health care.
May I suggest that you refer, visitors of your site who might want to
see a Chiro, to the Chiropractic Association of the state in which they
reside. Only licsensed, dues-paying, ethical doctors can belong to their
i'm going to cast a positive vote for ART chiro. it's main
drawback (in my opinion) is that it's active, and you need
to move (be active) and have good range of motion to get
maximum benefit, but it's quite helpful.
you can read more about it in this lengthy thread on tos forum:
actually, it gets 2+ votes now - i know of several people with
long-standing rsi problems that it has helped. i don't tout it
as "the solution", but it certainly may help if you get a
skilled provider that knows the upper extremity. treatment
can also include the shoulders/back/neck in addition to the arms.
it is a performed by specially trained chiropractors, so it
may be easier to get approval by workers comp than other helpful
it has helped with forearm tendinitis... more stamina, less
tightening. it has also helped someone with severe tos and
cubital tunnel syndrome.
In active release, the goal is to release adhesions along the
length of the muscles. For example, in the forearm pressure
is applied along usually the full length of the muscle from
origin to insertion while you (the patient) move from full
flexion to full extension. The amount of pressure is varied
depending on the tolerance of the person and what the chiro
feels in the muscles. They treat many of the muscles that
might be tight or contributing to nerve entrapment. The art
chiro will do several passes over the same muscle(s) until
they feel release. Because it is intended to break up micro-
adhesions (and fibrosis), it can have lasting results.
You have to give it a few sessions, but some people feel
improvement quickly. They say several times a week for
starters is good to let the practitioner get to know your
body... You have to continue to stretch regularly too.
I had terrible success with Medical Doctors, some success with Physical Therapists, but the best results came from my chiropractor (I had never been to one). The adjustments were great, but the most effect came from his use of the Active Release Technique (ART). Google this to find providers in your area.My chiro isn't listed, and he was even a teacher, because he doesn't want to pay the fee to be listed. So try calling around to chiropractors in your area and ask if anyone performs that technique. It releases the compressed nerves. I had almost 90% relief from 24/7 tingling in my hands and arms after a few weeks of this.
Paul's Note: Chiropractic is controversial. Along with the
comments above I feel obligated to include the following warnings
from a skeptical medical professional.
>My chiropractor really preaches the subluxation theory. Is this
>total BS? I know a few people who have had great luck with
>chiropractic care for other things. As for myself I have been
>going since my neck and back always hurt and do not have a normal
>curve. He is trying to correct this. Although I feel that my
>regular 1+ hours of stretching a night probably do me more good
>and cost less.
First of all, yes the subluxation theory is BS as it is fully unsupported
by any credible evidence whatsoever and there has been 110 years to find
it. IF the spine does not have a normal curve, I don't know how they could
know for sure, it is normally due to muscle activation patterns related to
how a person consistently uses their body.
>What is the general thoughts on chiropractic care out there. Is is
>a blessing or are we buying a modern version of snake oil. After
>2 months of 3 visits per week. I am still not sold one way or the
It would be foolish to suggest that chiropractic is complete hogwash on the
basis of the number of people that are under its spell (patients and
practitioners) to begin with. I consider it to be a fascinating social
phenomenon worthy of considerable exploration.
The actual treatments and advice vary from competent to outright quackery
and the risk runs from none to severe, depending on technique, target
structures and ideology. The trouble I have with chiropractic is that
there is no independently verified "benefit" to some adjustments (I am
speaking mainly of the neck region here) while it does carry a risk that is
difficult to ascertain in terms of frequency. In addition, if a person
went to several different chiropractors with the same problem, you will get
several different (and I mean DIFFERENT) diagnoses whereas that wouldn't
happen if you are seeing a physician or another scientifically trained
health practitioner (all else being equal, there are certainly incompetent
physicians out there and I am not talking about diffuse or vague complaints
either). Chiropractic has no real system of evidence, yet they
consistently avail themselves of pseudoscientific techniques like posture
analysis, thermography and EMG to try and convince the patient that there
is something demonstrably wrong (much like they use x-rays in the same way).
Many chiropractors actively campaign to avoid having their patients take
medicine or have their children vaccinated (the latter being especially
troubling and, in my view, amounting to nothing short of child abuse).
Many chiropractors say that they can cure diseases of all types including
thyroid, infections and a whole host of other things.
There are some and by some I mean a very few, who are competent
professionals that comply with standards like the Orthopractic guidelines.
In my view, if the chiropractor subscribes to subluxation theory, stay
away. You may want to visit the following websites for more info on safe
manipulation techniques and more skeptical analyses of chiropractic:
If you are trying chiropractic as a treatment, you should be aware that
recent studies have shown that abrupt, forceful adjustments of the neck
have been connected with a significant increased risk of stroke. The
thinking is that such adjustments cause trauma to a major artery or
arteries in the neck and shoulder region, promoting the formation
of blood clots that can subsequently break loose and cause a stroke.
You may want to ask your chiropractor to forgo this particular procedure.
I would like to reiterate the sentiment that unless there is a very
urgent need for a surgical intervention, at least get a consultation by
an Osteopath. It is excellent stuff.
All Osteopaths are qualified surgeons and have the same training as
MD's plus 300-500 additional hours of extensive training in bodily
manipulation including spinal, joints, & connective tissue.
The American Academy of Osteopathy
The original Osteopathic Med School is in Kirksville MO. have her contact the school for referrals. D.O.s are trained to be far more sensitive to the patient and have manual therapy skills that can be very effective for RSI, especially those trained at Kirksville, MSU (Michigan)or Pikesville KY. Some other schools have parallell tracked the manual therapy portion of their studies, leaving their students more likely to be closer to "plain old mds".
The most frequent problem I see is when a general practitioner, family
practice doctor, or internal medicine doctor, dabble in the area of
occupational medicine and try to diagnose these conditions based on the
relatively basic information found in Merck, DeGown/DeGown and similar
references. Family practice, general practice and internal medicine doctors
have the unenviable task of screening patients for literally thousands of
diseases. Because of managed care, health maintenance organizations and
health care reform, these doctors are increasingly being asked to diagnose
and treat conditions which are really outside their area of expirtise.
Even specialists like neurologists and neurosurgeons that don't understand
occupational medicine can fall prey to diagnosing people with TOS when they
really have RSI or SJD. Occupational medicine is a complicated field. It
takes a lot of advanced training and actual experience in treating ill and
injured workers to become proficient at it. I would encourage any person
who has a medical condition they feel is caused or aggrevated by their work
to consult an occupational medicine doctor.
In my experience, probably as many
as 80% of the reputed specialists in RSIs never look above the elbows, and I
think about the same percentage of injuries probably originate in
neurovascular compression in the brachial plexus area. But what do I know;
I'm a lay person! I definitely recommend that people look for
physiatrists--or osteopaths and chiropractors if they can't find
physiatrists--and question them about their understanding of hand injuries,
what percent of their patients have RSIs, what kind of therapies they
prescribe, and what has helped their patients. If they can't give specific
answers, thank them very firmly and move on. Some practitioners are very
knowledgeable about backs/necks but don't seem to understand that they are
related to what's going on in the hands/arms--as if the hands/arms belong to
one person and the neck/back belongs to someone else.
Early in my disability I visited a homeopath several times. I don't feel
that the medicines he gave me accomplished very much, but the sessions with
him were quite wonderful. He spent most of his time understanding my life,
attempting to put my injury into context. I think this is an incredibly
valuable thing, given that I got injured in the process of trying to prove
myself, overcome perceived failures of the past, and was caught in a
stressful relationship with my employer. By helping me to see my injury as
my body's way of saying that my life was out of balance, he turned it into
something with value rather than simply an experience of pain and loss.
I never fully recovered, and did quite a few other modes - from Chinese
herbs to Feldenkrais - still living with a certain level of pain depending
on what I do. Thanks to the homeopath I treat the pain as a guide and a
reminder that my priority is to value my health and the balance of my life
over all else.
One of my favorites when a doctor is avoiding my questions is to ask, "I
just want to be clear, maybe I misunderstood, are you refusing to answer my
question about X?"
I also bring a friend and a list of written questions, and have the
friend write down the answers. If the doctor doesn't have time to answer
them, I produce a stamped addressed envelope for her/him to mail back to
me with the answers. Then I call every few days until I get it back.
The friend I bring along takes notes to record what the doctor says.
Some doctors have let me use a tape recorder. I explain that the
examinations hurt, which impairs my ability to remember exactly what
he/she tells me, and I know whatever he/she tells me is important and I
want to get it right. Furthermore, this stuff is upsetting and I'm not
objective, so sometimes what he/she says and what I hear are not the same.
Why don't you try an Occupational Therapist. OT's are trained both in
mental health as physical dysfunction. OT's modify activities or physical
environments and fabricate assistive devices to enable a person to
function independently in self-care, work or leisure activities. And as
with most RSI's, activity or work station modification is the solution to
the source of the problem. Therefore, an OT is a qualified healthcare
professional to assist in this matter.
In my case I simply phoned the "South African Society of Occupational
Medicine" and asked for a Dr. with experience in "Work Related Upper Limb
Disorders" (as we call RSI over here), so there might be similar bodies
where you are. In any case, if Occupational Medicine is also medical
subspeciality where you are, that kind of Dr. could be closer to what you
seek, and should have ties with the Worker's Comp system.
Here in Adelaide I attend the Physiotherapy Clinic at University of
Adelaide. As I am on a disability-pension I get a full treatment for $15
which is quite a saving of the usual 35 to 50 out on the private world,
fully employed people only pay $25 I think. I get top class physios, either
physios employed by the Uni to provide treatment or at present I get
postgrads working for higher qualifications. I have been getting much
better over the weeks I have been seeing them, trigger point work on most
of the visits.
If anybody needs to have physiotherapy I suggest the ask around for any
local University teaching the subject, they nearly always have a program
where they will treat the public for reduced rates.
For those of you who feel unjustly targeted by your care giver try
something: Treat the care giver as a teammate and insist that they treat
you the same way. Be honest and supportive and insist that they be honest
and supportive with you. Give your best effort and insist that they give
you their best effort. And if you can't or they don't, then you need to
find another provider.
What I try to do is:
Learn as much as I can about the anatomy and origin of the problem(s) I
Consider who referred me: do I trust their judgement? Are they
knowledgeable? Have they given me good referrals in the past? Are they
desperate to refer me? What can they tell me about the practitioner?
Ask around and see what other people can tell you about them.
Find out about the background of the person I'm seeing. Interview them
beforehand on the phone. What can they tell me about their background,
and their knowledge of my problem? Do the communicate well? Do they
What diplomas do they display? What are the dates? Does this person
have a lot of experience? Do they take in-service training? Have I
heard of the granting institution? Do they have a broad background?
Look at the books on their shelves. Do I know any of them? Do they
look substantial, silly, pompous, clearly outdated?
How do they treat me? What do they tell me? Is it useful, does it fit
with what I already know? Are they willing to spend the time with me to
really talk about their findings? Does their treatment help
immediately, hurt immediately, or does their explanation of why it will
take time make sense? Ask questions. Speak up if you're puzzled.
Actually, NURSES are a great source for referrals, because they
often have worked with a number of local doctors, and because part of
their professional training involves comforting patients by talking, which
means they might be willing to spend a little longer...Occupational
nurses, in particular, are the front line workers for RSIs in most
workplaces. So if you are anywhere near a nursing college, like in
telephone distance, you just might get lucky if you call and ask what
doctors work with the occupational nursing program. FWIW. Try the
occupational health/rehab track.
I have often seen this term 'applied kinesiologist' emerge on the list.
Many of you will notice that the signature on my posts indicates I am a
'kinesiologist'. I think it is important to identify the significant
Kinesiology is defined as the study of movement and more specifically with
reference to the human body. It involves four basic areas of learning:
Biomechanical - force loading of body structures
Metabolic - energy systems and hormonal modification
Neuromotor - initiation and control of movement
PsychoSocial - internal and external non-physical influences on movement
These areas are specifically related to how they affect the movement of the
human organism. The training for this profession is scientific in
background and involves the completion of at least a Bachelor's level
We are often heavily involved in ergonomics as well as assessment and
conditioning of individuals. We are well qualified to assess all inputs
into any movement situation and are proponents of interdisciplinary team
approaches to all issues.
In regards to "Applied Kinesiology": I hate to have to say it but in my examination
of their theories and materials, this is a pseudo-science and a sorry lot
of hogwash, as sincere and well-meaning as it's adherents may be. It doesn't
get much fuzzier than this.
Subject: Re: physiatrists
May be source for MD in area and/or possible
guidelines for treatment
American Academy of Physical Medicine & Rehabilitation
One IBM Plaza, Suite 2500
Chicago, IL 60611-3604
<< Of course the items in the 'healing toolbox' are many. It is only by
using them together, in the right combinations pertinent to each situation,
I agree with you 100%, in fact in my book, this is the major theme. The RSI
sufferer needs an arsenal of health care providers all working together to
help the patient. My health center uses the same philosophy - I developed a
center that offers chiropractic, massage therapy, acupuncture, rehab,
nutritional counseling, guided imagery, naturopathy, and personal training.
(Even referrals to M.D.s when needed!)
Sharon Butler , Author: "Conquering Carpal Tunnel Syndrome and Other Repetitive Strain
Injuries: A Self-Care Program " writes:
The Hellerwork technique for releasing soft tissue injury is the best I've
seen yet - and I've seen a lot of it in my 10 years doing this work. At the
same time, Hellerworkers are skilled in teaching clients about making
effective changes in how the body is used, how to avoid future soft tissue
injury by using the body in a structurally balanced way, etc. In addition to
being the best form of myofascial release available (in my opinion), it can
also be some of the most effective ergonomic education as well. Hellerwork's
form of ergonomics is based on the individual's unique body structure and how
to maximize the balance of that structure while it is moving, working,
Not all Hellerworkers will be adept at treating patients with RSI, just as
not all Physical Therapists are successful with RSI. It is up to the patient
to ask the therapist beforehand if they have any experience in this area.
You can learn more about Hellerwork by checking out their
web page. I think you will find it a very
interesting site to visit.
But please remember: The History and Physical are much more important than
electrodiagnostic tests, MRIs, etc. So help the doctor out by preparing the
1. The chief complaint - what it is that's bothering you, i.e., pain,
paresthesias (pins & needles), numbness (loss of feeling), motor weakness or
other loss of strength and loss of range of motion. Those are the essential
factors of any musculosketal problem, be it CTS, tendonitis, TOS, tennis
elbow, etc. Write them down before you go in.
2. Your health history - all significant injuries or illness you have
suffered from birth onward. Particularly physical traumas, such as
fractures, MVAs, WC injuries, any injuries involving litigation, sporting
injuries, accidents around the house, etc.
3. The history of your present illness, accident or other dysfunction.
This should be time-related as much as possible, i.e., when you first
started having whatever is bothering you. It's important to list which came
first (pain, paresthesias, loss of feeling, etc.) and any relationship it
may have to your work, sports, hobbies, accidents and so on.
If you can make up a list like that -- type it up and keep it on your
computer so that you can amend it and adjust it from time to time. It can
become a diary, so that you can list doctor encounters, including
medications, PT efforts, chiropractic visits, etc., and what the results
were. Everyone should keep and start something like this on their computer
and keep it up to date, so they can print it out whenever an encounter with
a new doctor is planned.
But keep it terse. Just the facts, ma'm. Your doctor doesn't want to plow
through _Gone With The Wind_, and he or she wants to reading typing, _not_
It's very important to know the background and
training of any practitioners to whom you go for treatment . . .
I have been disturbed over the years by
the number of RSI "experts" who write books or give training and
certification, and yet have no definable medical or ergonomics training
or background themselves. . . . I feel it's really important to have some formal
health care training before you are qualified to give "treatment" advice
for RSI (which is, after all, a physiological condition). Ergonomists
can give ergonomics advice, but should not recommend or give treatment.
I myself had only one year of training as a massage therapist, so I
didn't feel qualified to write my book, Save Your Hands!, without having
a physician edit it. In any training I've ever given, I'm very careful
to suggest people see physicians, since I am not qualified enough to
give any treatment advice other than the most basic things (stop doing
what caused the injury, rest, icing, etc.).
This is just a form of "consumer protection" for people with RSIs. Be
skeptical about who you go to for treatment and advice, ask lots of
questions about their training and qualifications, and you'll be more
likely to avoid bad experiences with underqualified "experts".
Subject: how much of pt should be pain
This question raises an extremely important point.
I went from getting nowhere with physical treatment to starting to get
somewhere, when two things happened: first, I figured out "how
physiotherapy works", and second, I found a physiotherapist who
understood this too!
Physiotherapy is an interactive process. An essential part of it is
that you are aware of what effects the treatments are having on you, and
that you go back to your physiotherapist and tell your physiotherapist
about the pain or relief you feel in response to his or her treatment.
A good physiotherapist will work with this feedback, modifying your
treatment and coming to a better understanding of your condition, based
on what you tell him or her. There are many bad physiotherapists in the
world, so the more flexibility you have in being able to shop around,
The important thing is that when treatment doesn't work, or causes you
pain, you mustn't think that it's because there is something wrong with
you (that you have a low pain threshold), or that it's because your
physiotherapist is bad or stupid: your physiotherapist is only bad or
stupid when he or she can't work with your feedback when you tell him or
her that it causes pain.
As for "good pain" and "bad pain", there are different approaches to
this, and in the end you need to listen to your own body to figure which
is right for you. Many people in Toronto have had great benefit from an
extremely painful dry needling procedure -- for this form of treatment,
the phrase "no pain, no gain" might be appropriate.
Some people benefit better from a gentler approach: I go to a very
gentle physiotherapy clinic, where the phrase "no pain, no gain" is
banned; here the standard is that the treatment should not cause you
more than 24 hours of flare-up. This happens to work for me.
It's fairly normal for an assessment to cause a flare-up, since part of
what goes on in assessment is the attempt to reproduce your symptoms.
I'm not in your area, but for type of doctor I finally found one associated
with a teaching hospital that has been a good "gate" to physical therapy,
etc. His department is Physical Medicine & Rehabilitation. And he
specializes in Occupational/Muskuloskeletal Medicine.
I find the therapist is the real key to understanding and treatments. I
found two good, very educated ones (physical therapist and occupational
therapist) at a rehab facility with sites on the east coast, so look for a
rehabilitation facility in your area (you'll need a doctor referral
probably). I've also had a certified hand therapist but the occupational
therapist is just as good.
If you can, type or write out a timeline of your pain, discomfort, etc. and
take it with you.
When you go to the Dr., they should do some tests, like a grip test, a
finger/thumb pinch test, to see how strong you are. They should do a good
evaluation and history and ask you lots and lots of questions. They should
let YOU ask lots of questions. If they don't, get your purse and walk out.
The first doctor (ortho hand surgeon) I went to, did NO eval, no tests or
history, was in the room for total 10 minutes, asked a meager couple of
questions like 'did I ever fall'; hey!! I said it was from a computer!! No,
I didn't fall on my computer! Then he gave me a horrible cortisone shot. He
didn't ask me, he didn't discuss it, he just said "I'm going to give you a
shot and come back in 2 months." And he put me in a splint. I cried all of
the way home.
I was so shocked that he didn't want to talk to me or answer my dozens of
questions that I just did what he said and got the shot. BIG MISTAKE!!
I was in pain for 5 weeks, 24/7. I had never had that much pain before with
I requested a 2nd dr. (also Ortho hand surgeon) and when I went to see him,
I was so nicely surprised to have someone do all of these grip tests,
x-rays, fingertip sensitivity tests, then an hour-long eval with a
physician's assistant, then 45 minutes with the doctor. It was wonderful!
They actually cared. They wanted copies of some 'proper use of computer'
info I got off the internet, as well as the 'body map' to keep track of
discomfort. He looked at both hands, had me move my fingers and hands all
around, had me show him how I used to choke my mouse and hold my clicking
finger up high, etc. to cause the pain.
They recommended physical therapy, and lots of different ideas to try. It
has now been 8 months, my tendonitis in my hand is gone, my forearm doesn't
hurt anymore, but my wrist joint is still lose and cracks and pops out of
place. I am now going to have arthroscopic surgery on my 'distal radio-ulnar
joint', and a possible ECU tendon re-alignment on Jan 31.
Good luck!! Take someone with you. If you feel the least bit
uncomfortable, walk out of there. It's your body! And no one cares as much
about you as you do! A doctor who cares about you will also help heal your
'heart', and understands what it feels like to go through all of this.
Reading comments about physicians, as if they don't differ in interest in
and knowledge about RSD, RSI and related issues, is rather frustrating,
since I've seen it from the other side of the stethescope.
Since I was interested in RSI, CTD, RSD and related conditions, I often
had people come to me after they'd seen some number of previous physicians.
They were often very frustrated with the lack of interest in and knowledge
about these conditions on the part of these other physicians, whic was
Then I would talk with other physicians about this, and some of them
expressed huge frustration with patients that would not take advice, not
follow through with appointments, expect the doctor to prescribe a magic
pill or some quick treatment that would fix everything up right away.
Then my wife developed some unusual symptoms and signs, accompanied by
psychological problems from lack of sleep and chronic pain, for which we
saw more doctors than I ever want to have to see, again, and I saw actual
stupidity, even cruelty, on the part of physicians, despite their knowing
that I was a physician. I found it highly upsetting at times.
What stands out the most, though, is those physicians that did care, that
took some time to try to understand, and that, even if they couldn't work
any magical treatment or cure, could at least try to help. I respect and
regard them highly.
So, don't put up with uncaring attitudes, dismissal, incompetence and
unwillingness to try to understand. There are physicians that are worth the
extra effort to find, and this SOREHAND group, with "FindaDoc" and the
sharing of names of good physicians, assists greatly in that search. I pray
that those who are still seeking will find those who can help.
First of all, I would like to reiterate (read knock you in the
head until it really registers) how important it is to continue
to search out and see the best specialists. In many cases
you may have to travel some distance to reach them. But
there is a world of difference and it is well worth it. ...
Based on my experiences I offer you the following
If you think you have Carpal Tunnel, Tendonitis, or similar
problems bypass "general" Orthopedic Specialists and see a
Hand/Upper Extremity Specialist. If you think you have a more
complicated problem such as TOS, see a Hand/Upper Extremity
Specialist _and_ a Neurologist which concentrates on peripheral
neuropathies _and_ make sure both of them see alot of (potential)
TOS cases. When it comes to physical therapy, go to those that
the above specialists recommend. While there are exceptions
(and some of those exceptional people participate in this list), I
believe my suggetion is a good rule of thumb. Also... I would
strongly suggest you consider seeing doctors which are part of a
Having seen a number of Neuro's and Ortho's, I have realized
that they do have different approaches to diagnosis. When
appropriate, the Neuro's do a variety of blood work, take
MRI's of the brain, do nerve biopsies,etc in an effort to rule-out
general neuropathies and various diseases which can mimic
problems such as TOS. It has been my experience that the
Ortho's don't look for such things. On the other hand, Neuro's
probably don't understand some of the other issues (such as
tendonitis, connective tissue problems, etc) that Ortho's do.
Which is why I am glad I am seeing both and recommend the
same to you.
I don't mean to be long-winded, but I felt it was important, especially
if you get many hits from people seeking help for work-related RSI, that
I needed to explain in some detail about the specialty of occupational
To give you a little background, not only for me, but in the specialty
of occupational medicine:
I am residency trained (at the Unviersity of Michigan) and board
certified by the American Board of Preventive Medicine (ABPM or
in the field of Occupational Medicine. Part of doing the residency
includes getting a Master of Public Health (MPH) degree.
Many physicians who claim to be specialists in the field of
"occupational medicine" just happen upon that type of practice as a way
of getting more business and thereby more income. However, many of
these physicians do not have the proper training to practice in this
field. There are only a relatively small number of physicians who have
actually completed a full residency in occupational medicine, which is a
2 year program after one also completes a one year clinical internship
(total of at least 3 years).
Our (occupational medicine) board certification is by the American
Board of Preventive Medicine, which is one of the only 24 specialty
boards recognized by the American Board of Medical Specialties (see
and click under Preventive Medicine). A board approved by ABMS differs
from the so-called self designated boards which are set up by various
and sundry people without regulation and without approval by ABMS - such
as the "American Board of Environmental Medicine."
"The American Board of Medical Specialties (ABMS) is the umbrella
organization for the 24 approved medical specialty boards in the United
States. Established in 1933, the ABMS serves to coordinate the
activities of its Member Boards and to provide information to the
public, the government, the profession and its Members concerning issues
involving specialization and certification in medicine. The mission of
the ABMS is to maintain and improve the quality of medical care in the
United States by assisting the Member Boards in their efforts to develop
and utilize professional and educational standards for the evaluation
and certification of physician specialists."
Thanks for reading this and I hope it helps in your understanding of
In short, OT is a health profession whose ultimate
goal is enabling clients to engage in those activities that s/he both
wants and needs to do. We accomplish this goal in two ways: increasing
the underlying skills necessary to perform that task: and adapting the
environment or activity to meet the abilities of the individual. For
example, a person suffering from carpal tunnel syndrome could be fitted
with a ulnar cock up splint that would keep the wrist in a neutral
position and keep the carpal tunnels open. Although OT is usually
associated with rehabilitation settings, we also work on prevention as
According to two studies I have read, on CTS and massage therapy,
massage significantly improved the condition of over 90% of subjects.
In the study, half were on disability and after three months treatment,
they were all able to return to work (some only part-time.) In about 75%,
it was completely cured. Compare this with the rate of those with improvement
after surgery(40%). I suggest trying less invasive procedures like massage
therapy, or physio before resorting to surgery. Physiotherapy has a
lower rate of improvement than massage therapy, but it has the advantage of
being mostly covered under OHIP. (Musicians, I find don't always have the
money for MT.) If physiotherapy doesn't work, it at least does no harm.
If you have the money or workplace extended health care, then go straight to
a massage therapist after seeing your doctor. It is your best bet.
The results in my practice back up what I have read.
Bowen Therapy and Osteopathic manual therapy both helped me
and also the people I worked with, including those with DeQ. I am a therapist.
Bowen was and is the most helpful. It is a gentle and noninvasive and fast acting hands
on therapy. If you want the name of a therapist near you contact Allie Powers at the US
headquarters at firstname.lastname@example.org and she can tell you . OMT trained P.T.s or osteopaths
may be hard to find but try the osteopathic websites for your area.
Some background info on osteopathy .
I live in South Africa and so I doubt my experience will help you there.
In my case I simply phoned the "South African Society of Occupational
Medicine" and asked for a Dr. with experience in "Work Related Upper Limb
Disorders" (as we call RSI over here), so there might be similar bodies
where you are. In any case, if Occupational Medicine is also medical
subspeciality where you are, that kind of Dr. could be closer to what you
seek, and should have ties with the Worker's Comp system.
Hiya! I was really excited to find your MUSICIANS AND INJURIES website;
I'm a guitarist/singer and professional licensed massage practitioner(LMP), and understand
the ways in which repetitive stress can make the joy of music seem like a
painful chore. I looked through your first few pages and did not see
massage therapy included. All of the most common problems, from thoracic outlet to
carpal tunnel, to low back pain and such, are all common to massage therapists. We see
them daily, and are able to effectively treat our clients, as well as recommend
"activities of daily living"-stretches, water intake, and the like.
Have you considered massage therapy in your possible list of treatments. I
just wanted to make sure that you are not overlooking what seems to
me to be a natural type of healing help.
(The following copyrighted material is reproduced with permission from:
Carpal Tunnel Syndrome: How to Relieve & Prevent Wrist "Burnout!"
by Rosemarie Atencio Copyright*1993 Rosemarie Atencio pp. 49-51
HWD Publishing, PO Box 220 XA, Veneta, OR 97487. (503)935-1608
FAX (503)935-0705 $13.95 + $2.50 s/h)
IF YOU NEED TO SEE A PROFESSIONAL:
1) On a piece of paper, write a list of your symptoms. Here are questions for
you to consider:
(In addition to the specific symptoms, you need to be
prepared to briefly describe any traumas or accidents
that you may have had to the neck, shoulders, arms and hands.)
What are the sensations?
- Where are these sensations?
- What time of day do the symptoms occur?
- What are you doing at the time that you have symptoms (asleep,
specific movement at work..) ?
- What makes you feel better?
- What makes you feel worse?
- What treatment(s) (drugs, splinting, etc) have
you tried that did not work?
- How long did you stay on the treatment?
- How long have you had the problem?
2) On the same piece of paper, write down the information about your lifestyle
- What physical actions are required on your job?
- What are your hobbies?
- What kind of physical activities do you do regularly?
- Do you participate in any sports?
- Do you sleep well?
- Do you eat well?
- Do you take any drugs or supplements?
3) Finally, list the questions that you have about the professional people and
the course of treatment that recommended. ( Be bold! You are the consumer.)
Copyright*1993 Rosemarie Atencio
- How long have they worked with cumulative trauma or repetitive motion
- What is the course of treatment that they recommend for such disorders?
- How do they feel about second opinions?
- How do they feel about cooperating with other professionals (physical
therapists, acupuncturists, osteopaths, for example)?
- What results would they consider satisfactory?
- How long would they continue a specific course of treatment?
- If surgery is required, what arrangements do they have for after-care?
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