February 27, 2004
This is the story of how I developed Repetitive Strain Injury (RSI) in my hands and how they were eventually cured. It also surveys current medical practices used to cure such injuries and leads ultimately to an inquiry into the relationship between the mind and the body. Many medical practitioners may find that my case suggests a new path for those patients with RSI who seem beyond the reach of traditional treatments. This story will also help the patients themselves, not only those who suffer from RSI but also those that suffer from other tension-related disorders such as backache, leg pain, rashes, migraine headaches and fibromyalgia. Finally, I am writing this for Dr. John E. Sarno, whose work has led to my cure.
I had my first bout of RSI in 1997 when I resumed playing the piano after a two-year hiatus. I was at the Grade 10 level and would practice about an hour per day. At the time I was also working at a 10-hour per day computer programming job at an unergonomic workstation. After suffering through a few days of pain, I stopped the piano playing, got a better mouse and my symptoms went away after a few weeks. Over the next three years I had several similar short-lasting bouts.
In the Fall of 2000 I began playing the piano again, this time after having stopped for about a year. A month later I attended a seminar on RSI. At the time my hands were fine but about two weeks later I felt the symptoms of RSI. They came on fast and didn’t go away. My hands became quite weak and painful and the piano pieces I was working on stopped improving.
I started upper-body massage therapy with a therapist who specializes in musicians’ injuries. I was able to complete my piano course and perform my pieces for a jury but when I tried to learn new pieces in January of 2001 I could barely play a line of music without pain. I found this odd since I could play my other pieces without pain, one of them eight minutes long. I had to give up playing the piano. From this point onward I found I could only work at a computer for about an hour per day before experiencing pain. I continued to have some massage therapy but things didn’t improve. When I finished my Engineering degree I stopped working with computers for a couple of years.
In 2003 I was living at a Zen Buddhist monastery and began programming an Internet site for them. I was amazed to see that my hands hadn’t healed at all but were in exactly the same condition as two years before. I started working slowly, taking 10-minute breaks every 10 minutes and working about five hours a day. I did everything I knew to protect my hands and also got the advice of a local doctor. I would do stretches, Qi Gong exercises, yoga and apply ice to my arms twice a day. Nevertheless my condition continued to deteriorate.
I researched RSI quite thoroughly and bought Pascarelli and Quilter’s highly regarded classic Repetitive Strain Injury, A Computer User’s Guide. It made sense to me. I decided I had some pretty extensive soft tissue injuries, from the neck and shoulders down to my forearms and hands, caused from overuse. The soft tissues were inflamed and so pinched the nerves and arteries at several points resulting in weakness and numbness in the hands. I thought all I needed was to get an expert to give me an accurate diagnosis and then to go for a course of massage and physical therapy and I’d be as good as new.
I happened to discuss my condition with one of the Zen teachers at the monastery. He suggested that I needed to get into the habit of relaxing my hands and body and that would take care of things. At the time I thought such a view was naive. I thought my problem and its cure were structural and that relaxing my hands had nothing to do with it. In fact, I thought the reason my hands were so tense was because I had structural damage. One of the local doctors suggested I had a big “psychosomatic” influence that had a lot to do not only with my RSI, but also with the pains I was having in other parts of my body. I considered that there may be some truth in this but there didn’t seem to be anything I could do about it.
Still certain that my RSI could be understood and cured by the Dr. Pascarelli approach, I stopped using computers and started going to a specialized RSI clinic. I went three times a week for physiotherapy, massage therapy, and a form of trigger point release called dry-needling. I continued my daily yoga and started taking vitamin supplements to enhance my diet. Each day I would also do contrast baths, lots of stretching and even healing visualizations.
During this time my body seemed to loosen up and my muscles became more relaxed. I also seemed to develop a greater awareness of the blood flow and health of my hands. Yet I still found I could not work on a computer for long without experiencing pain. In fact, my condition seemed to be getting worse. I was able to work for about an hour each day at the beginning of the therapy and three months later I could only work for about twenty minutes. Furthermore, I began experiencing pain when I wasn’t even at the computer and also when doing certain poses in yoga. This wasn’t making any sense to me. I went for a nerve conduction study but it showed my hands to be functioning normally.
After about two and a half months of therapy my doctor started asking me if I had considered any other careers, ones in which I wouldn’t need my hands so much. I realized at that point that this approach of healing, assuming a structural cause of the pain, wasn’t going to work for me. I didn’t give up all hope though.
I went back to the Internet to look for approaches to treating RSI that I had missed. That week I came across the Dr. Sarno school of thought, one that assumes a psychological cause for RSI. It immediately struck a chord with me. I read these points off a website:
To heal RSI you need to use your conscious mind to override your autonomic response, which is cutting off the blood flow. The most effective way to do this is to adopt the beliefs of those who have cured their own RSI. The longtime RSI sufferers I know who have recovered 100% have all adopted a set of beliefs, which I have distilled to the three keys below.
1. RSI symptoms are due to a lack of blood flow to the arms.
2. In RSI, the autonomic nervous system turns off the blood flow inappropriately.
3. The conscious mind can veto this blood flow strike.
When you adopt these beliefs, you begin to regain control of your health. You are not afraid of the pain anymore, because you realize that it is not a sign of irreparable harm. You have enlisted your conscious mind to be alert at every turn to override any impulse to cut off the blood to you arms. Over time, your mindbody will learn to maintain adequate blood flow to your arms. You will heal. Furthermore, these new beliefs will act like antibodies, protecting you from any recurrence of your symptoms (McNamara).
Because of all I had gone through I could immediately believe this theory. That day I worked thirty minutes on the computer and at the end of the time my hands felt warm and strong. I seemed to be able to keep the blood in my hands though I didn’t know how I was doing it. I ordered the books recommended by the web site.
Fred Amir’s book called Rapid Recovery from Back and Neck Pain sums up Dr. Sarno’s discovery best:
Dr. Sarno, a professor of clinical rehabilitation medicine at the New York University School of Medicine, discovered that back pain [and other ailments like RSI] is almost always caused by anger, anxiety, worries, frustration, and tension—not some physical abnormality. He calls this phenomenon tension myositis syndrome (TMS). TMS is the result of reduced blood flow to affected soft tissues. Although extremely painful, the condition is harmless; what is going on is that the subconscious mind is creating pain to distract the person’s attention from a stressful relationship or situation.
Once the patient is aware that back pain [or RSI] results from repressed anger or anxiety, the subconscious mind will discontinue its trick, and the pain will stop. TMS sufferers are usually perfectionists who want to be the best in whatever they do and are their own worst critics (66).
Here is a passage from Dr. Sarno’s book, The Mindbody Prescription, that describes the initial consultation of a typical TMS patient:
Your pain may be in the low back, accompanied by numbness, tingling or weakness in any part of one or both legs. It may be in the middle or upper back. Or it may be in the neck and shoulder, with pain, numbness, tingling or weakness in one or both arms and hands. It may be in the shoulder joint region, the elbow, the wrist, the fingers, the hip area, the knee, the ankle, the top or bottom of the foot, on one or both sides.
All of these are common manifestations of TMS.
The pain may be worse during the day or at night. It may be severe when you first awaken and try to get out of bed, gradually improving as the day goes on; or you may be at your best when you get up in the morning and suffer increasing pain in the course of the day. It may be aggravated or improved by sitting, standing in one place or walking. You may be afraid to bend or lift; if you can’t do those things you will not be able to do your job, run or engage in any sport or exercise. You may be afraid to do anything physical, no matter how easy the task or maneuver.
Or you may have continued to be physically active, including participating in vigorous sports, in spite of the pain. You may get pain at strange, illogical times and not get it when it seems you should.
These are all common scenarios for people with TMS and are classic examples of how they become programmed to have pain at certain times and in association with many different activities or physical postures.
Most of the time you are under the impression that something is wrong with your back or neck or shoulders, a structural defect, deterioration or degeneration of parts of your spine, a bulging or herniated disc, fibromyalgia, a tear or strain in a muscle, tendonitis somewhere. These diagnoses are usually supported by X rays, a CT scan or MRI studies and it is highly likely that your pain got considerably worse when you learned what these tests showed.
Your life may be literally dominated by the pain syndrome; it haunts your waking hours. You have been to many doctors and tried many treatments, but, though it is sometimes better for a while, the condition invariably returns.
Your family and friends are sympathetic and constantly warn you to be careful.
I have learned all these things from you in the course of taking your history. The physical examination disclosed either no objective neurological abnormalities or a variety of relatively minor ones like the loss of a tendon reflex, some mild weakness or change in the perception of a painful stimulus like a pinprick. Some of you had extremely limited ability to move around, maneuver on the examination table or bend over, and others were remarkably agile. Virtually all of you, however, experienced pain when I pressed on certain muscles in the lateral buttock, the small of the back and the top of the shoulders. Additionally, about 80 percent of you felt pain when I pressed on the long tendons on the side of both thighs.
Because of the physical findings and the history, I concluded that you had TMS and proceeded to tell you what that meant. I said that the structural abnormalities previously identified were not the cause of your pain and I would present evidence then and in the course of my lectures to buttress that conclusion. The pain, stiffness, burning, pressure, numbness, tingling and weakness were caused by mild oxygen deprivation in the muscles, nerves or tendons involved in each case. In itself this was harmless. Although it could produce more severe pain than anything else I knew of in clinical medicine, you would not be left with residual damage when your symptoms disappeared.
I then proceeded to explain why the brain had seen fit to reduce the blood flow to these areas, causing the distressing symptoms; how the rage and other powerful feelings in the unconscious were threatening to break out into the consciousness, and the pain had to be created as a distraction to prevent that from happening. In most cases you were aware of the important psychological factors, like the stresses in your life, perfectionism and goodism or childhood trauma, that were responsible for your pain. You were reassured that resolution (cure) would come with understanding of the process. I said that all of this would be amplified and clarified in the course of two basic lectures, since there was not enough time to present the entire story during an office consultation. We will have spent forty-five minutes together (139-141).
I looked back at the time in the Fall of 2000 when I first had full-blown RSI. I was a perfectionist in my last year of an Engineering degree. Prior to the onset I was struggling with anxiety and insomnia. At the time I even considered dropping out of school because I was suffering so much. Shortly after, I developed RSI and around the same time my anxiety and insomnia became manageable. It is also interesting to note that the RSI affected the very tools I needed to give a “perfect” piano performance, to write “perfect” essays, to program “perfect” algorithms, my hands.
Sarno goes on to claim that after his initial consultation and the subsequent two lectures that cover the diagnostic issues, the psychology, and the treatment of TMS, 80 to 85 percent of patients become pain-free within a matter of weeks. For these people, the knowledge of how and why TMS functions is enough to thwart the brain’s strategy. Those who continue to have significant pain attend weekly meetings at which the key features of TMS are reviewed. If pain persists, a deeper exploration is necessary and psychotherapy is prescribed. This is successful in most cases leaving only about 5 percent of patients overall who continue to have significant pain (158).
Sarno does admit that there may be some cases of back pain, or RSI, that are the result of a structural abnormality but in most cases he finds that the cause is TMS (143). He attributes most benefits obtained from traditional treatments, like physical therapy, medication and surgery, to the placebo phenomenon (155). These benefits are almost always temporary while those due to TMS treatment are almost always permanent (156). Dr. Sarno provides a lot of convincing evidence to support his claims.
He also explains how TMS can undergo “location substitution.” People who have a tension-induced backache, once they have traditional therapy and consider it “cured,” may begin to have pain in their feet, or develop a skin rash or some other psychosomatic disorder to play the role that back pain used to fill in distracting them from their repressed emotions (167) (See Appendix 1 below for a complete list of the forms of TMS and equivalent psychosomatic disorders).
For myself, this explains a whole pattern of physical pain I have been enduring for the past several years. I would experience pain in the lower back, would worry about it and would do all sorts of exercises for it. The pain persisted so I changed the way I moved, would avoid sitting in soft chairs, etc. There were times when it would go away and during those times I would be frustrated with strange knee pains that would prevent me from standing still or walking on concrete floors. I would also struggle with weak ankles and would avoid walking on uneven grassy fields. But I usually seemed to only struggle with one of these pains at once. The only explanation for my condition was that I was sensitive and had a weak body. I found this hard to accept since I was athletic and had spent a lot of my life playing competitive sports like soccer, rugby and downhill skiing. Now, I believe that all these pains were harmless and were merely TMS.
Dr. Sarno also explains how this “location substitution” operates on a societal level. Ulcers used to be in vogue but during the last twenty years, backache, RSI, and garden-variety allergies have risen dramatically and the ulcer is fading into obscurity. The reason for this switch is that, in the early eighties, psychological tension became the generally accepted cause of ulcers. The whole purpose of the ulcer was to distract the individual from this tension and now it no longer worked. In a sense, society came up with replacement psychosomatic disorders to achieve this same purpose (xxiii).
This reminded me of how I got RSI two weeks after I went to a seminar on RSI. Perhaps this seminar “suggested” to my subconscious that RSI would be a good way to distract me from the intense anxiety and insomnia I was suffering from. I do recall that after the RSI became full-blown, my anxiety and insomnia became manageable and not really a problem. Curiously, two other piano students who attended the same seminar also developed RSI around this time and had to start getting treatment.
I also remember during the year when I was living at the Zen monastery and was complaining to people about my RSI, three of the thirteen people I was working with began to get RSI symptoms for the first time in their lives. This supports the theory that RSI may in part be an epidemic hysteria—a psychosomatic disorder that is now in vogue, as Sarno suggests. This goes against Pascarelli and Quilter (Pascarelli and Quilter 11). They would argue that RSI wasn’t suggested to us but that all along we had a minor form of RSI and, in the first case, the seminar simply brought it to our attention, or at the monastery, my complaints of RSI simply made the three other people aware of the RSI they already had but weren’t previously aware of. I don’t find this interpretation convincing. From my experience, I agree with Dr. Sarno and think that the way TMS manifests (RSI, back pain, knee pain, etc.) can be influenced by suggestion from society and individual people.
While Dr. Sarno’s book lays down the theory and evidence for TMS, Fred Amir’s book sets out a very effective method for recovering as quickly as possible. He understands TMS to be a deeply conditioned pain response, a habit, and provides a number of practical tools for de-conditioning the mind, to break the habit. They include positive thinking, mental exercises, setting short and long-term goals to gradually return to regular use of the injured body part, rewarding oneself with good results, and body relaxation techniques.
In one example of positive thinking, he asks me to close my eyes, take a deep breath, clench my fists, concentrate, and repeat five times, “I am not going to hurt anymore. I will certainly win my battle against pain” (168). In one of his mental exercises, I close my eyes and imagine doing the normally painful activities without the pain (175). Some of these felt a little silly to me at first but I tried them anyway and found that they helped. Often any pain and fear I was feeling would go away immediately and be replaced by a feeling of strength and well-being.
Dr. Sarno recommends discontinuing all physical treatment since he believes that until a patient renounces all physical approaches, he or she is still hanging on to the belief that some structural problem is to blame. Focusing on that possibility causes the pain and other symptoms to continue (Amir 80). So I cancelled my appointments at the RSI Clinic and stopped doing my daily stretches and contrast baths.
I set my goals for gradually increasing my time on the computer each day. One week later I was working at the computer for about 45 minutes each day. At the end of the second week I was up to an hour and a half and by the end of the third and fourth weeks, two and a half and three and a half hours. I also met goals for doing particular yoga postures that I had stopped doing due to the pain in my wrists.
It is true that on some days during this period I did still have pain, especially during the first two weeks. I rarely felt pain at the computer but I would feel it when I was out socializing or just reading a book. I suppose at these moments my doubts about TMS would get the better of me. I also found my mind making the excuse that, “Well, since I had just done some stressful yoga poses, I should expect to feel pain.” I learned that this didn’t have to be true. I started to pay special attention when I was socializing or reading because it was in these situations that my mind was conditioned to reduce the blood flow to my hands. As the weeks progressed my hands would hurt less and less even though I was increasing my use of them. I began to gain more confidence and wouldn’t fear the onset of pain as much.
I extended my understanding of TMS to other body parts such as my lower back and started sitting in chairs that would normally make it ache. Before sitting down I would dare my back to hurt. If it did start to hurt I would just laugh it off, believe that it was just a trick my mind was playing, and try to let blood flow back into the muscles. Usually the pain would subside.
Today, five weeks after encountering Dr. Sarno’s theory, I am working for five hours a day on the computer. I consider myself 90% healed. I haven’t felt any pain for about a week. Other than occasional weak feelings in my hands when I wake in the morning, they feel strong and healthy. I haven’t worried or feared for their recovery in a few weeks. I continue to do the mental exercises because I think the de-conditioning is still taking place. I feel ready to engage this process while playing the piano and will set out goals to build my endurance like I’ve done with the computer work.
The more I experience and study how the mind interacts with the body to cause TMS, the more I see it as just part of a larger phenomenon. Just as the mind causes physical pains to deflect attention away from itself, so it also generates all sorts of mental activities to achieve the same aim. These come in the form of memories, desires, passions, anger, fear, thoughts about the future, the repetitive sound of a song, fantasies and so forth. All of these, just like the pain from TMS, are harmless, but we usually don’t realize this. We get caught in these agitated thoughts and emotions and this is precisely why they are so successful at consuming our attention. The cure for them is the same as the cure for TMS: to acknowledge the particular mental activity that arises, see it as harmless, and then to let it go. Eventually the mind will tire of the game, now that it no longer works in consuming our attention, and it will become more peaceful. This is nothing other than the basic meditation practice of many religious traditions. Furthermore, the cure for TMS has always been available as meditation. Perhaps without realizing this, modern medicine and psychology have dressed it in clothes to make it accessible to the secular world.
This report comes from just one case of RSI and all conclusions it extends are therefore speculative. However, I believe that my case is a typical case of TMS, from the behavior of the pain to the swiftness of the recovery. One should read Dr. Sarno’s books for statistically significant studies that document the prevalence of TMS in Western society and the simplicity of its cure. I consider myself fortunate to have discovered Dr. Sarno’s work and to have cured my RSI but I would have been more fortunate to have discovered it earlier. The purpose of this report is to promote Dr. Sarno’s work in order to hasten the cure of others suffering from unnecessary pain.
Please send comments or questions to ChristopherJAbraham@hotmail.com.
This is the complete list of ways in which TMS can appear (Sarno 43):
- Most low back and leg pain
- Most neck, shoulder and arm pain
- Possible cranial nerve pain or weakness (fifth and seventh cranial nerves)
- Tension myalgia
- Myofascial pain syndrome
- Temporomandibular joint syndrome
- Most tendonitis syndromes
- Carpal tunnel syndrome
- Reflex sympathetic dystrophy
- Post-polio syndrome
- Most chronic pain
- Most of those with so-called chronic fatigue syndrome
- Most of those with the Epstein-Barr syndrome
This is a list of equivalent disorders that work in the same way as TMS (Sarno 44):
- Gastrointestinal disorders (heartburn, ulcers, irritable bowel syndrome)
- Disorders of the circulatory system (tension headache, migraine headache, Reynaud’s phenomenon)
- Skin disorders (acne, eczema, hives, psoriasis)
- Disorders of the immune system (allergies, frequent colds, urinary tract infections, recurrent herpes, yeast infections, prostatitis)
- Genitourinary disorders (frequent urination)
- Benign disorder of the cardiac mechanism (aberrations in heart rate and rhythm)
- Miscellaneous disorders (hypoglycemia, dizziness, tinnitus, spasmodic dysphonia)
Amir, Fred. Rapid Recovery from Back and Neck Pain. Santa Clara, CA: Health Advisory Group, 1999.
McNamara, Nate. “Conquer RSI.” Internet: www.conquerrsi.com/handout.html. February 13, 2004.
Pascarelli, Emil, and Deborah Quilter. Repetitive Strain Injury: a Computer User’s Guide. New York: John Wiley & Sons, 1994.
Sarno, John E. The Mindbody Prescription. New York: Warner Books, 1998.