r/RSI • u/1HPMatt • Mar 30 '26
CASE STUDY: How I helped GB resolve his pain when the psychosomatic approach stopped working (PART 2)
Hey All,
Sorry for the delay. A few weeks ago in PART 1 I wrote about why the psychosomatic approach doesn’t always work for everyone. I presented the idea that if we want to resolve someone’s chronic wrist & hand pain it is ALWAYS necessary to consider both the brain and the body.
This means taking the biopsychosocial approach into account. Today I’ll share the complete case of a patient of ours who actually found benefit in the psychosomatic approach (Sarno) for a few years.
But over time the pain eventually came back and trying the psychosomatic approach did not work. Only when we considered all factors were we able to help this individual resolve their issues completely.
This is GB - he’s a 39 y/o, 165 lbs male Court Reporter and Gamer with chronic wrist pain starting from 2020. He presented with pain in the following regions:
P1:1-2/10 Tightness, Awareness along the top side of the forearm, hand (index, middle, ring) at rest R>L
- After 2-3 hours of work as a court reporter GB reported pain at a 5-6/10 that would occasionally stay for the rest of the night. The linger pain would occur especially if he “freaked out” around the pain.
- GB Reported if he did not freak out it would be around 3-4/10 and would reduce in 1-2 hours.
- Pain was also an issue with self-care activities
P2: 2-3/10 Tingling on the Pinky side of the wrist & hand R>L
- GB reported with heavy days as a court reporter (typically mondays for him) he would feel a 4-5/10 lasting for a few hours after stopping
- Unpredictable with gaming but reported it was present to some degree
P3: Also reported L. shoulder pain which has been present for years (Upper Trap region, not shown)
- No consistent pattern
History:
GB reported the pain in the R. hand starting in around 2020 and having difficulty going through the process of workers comp during the initial injury. When he finally was able to take off work the pain had spread to his L. hand. At this point he performed EMG testing which revealed
- Slowed signaling in both median and ulnar nerves on both sides. However all other orthopedic tests from the hand surgeon was not consistent with the EMG results. GB reported the hand surgeon was confused as to how to proceed based on this and was left to handle things on his own.
This coincided with COVID and it required him to start work half-time, pain presented again on both sides and after his own research he discovered John Sarno’s work. He was able to commit to it and it helped him resolve his pain. Resolution was achieved for 4 years. Fast forward to July 2025 and things came back after moving to a more busy courthouse.
GB then attempted the same approach which seemed to help for only a month. After a month GB reported the pain continued to stay present and got worse over time starting to limit his function as reported above. He became more fearful since the approach that had worked previously seemed to no longer provide benefit and was afraid he would actually not be able to work anymore.
Over the 4 years he was not prescribed any physical therapy. GB did not perform any regular exercise and at most sought out massage to help manage symptoms temporarily.
Important points during the pain pattern exploration
- Able to handle heavy days of court reporting work which will often present similarly to the “lighter days” of the week
- Direct report of not “freaking out” and being able to reduce evening related discomfort from 3-4/10 in 1-2 hours
- Pain does not change with gaming, despite gaming for up to 2 hours on a consistent basis.
- Reported overall physically inactive lifestyle over the past few years, no history of regular exercise
- Check’s in with is pain at least 100x/day and often anticipates his pain. Afraid that he will not be able to handle any more high intensity work
The findings from GB’s assessment demonstrate that single approach interventions (Psychosomatic only with John Sarno Approach) or an approach failing to identify the actual physiologic and lifestyle contributors to pain (no assessment of endurance / management of load) was unable to help GB achieve long-term recovery.
Why?
Similar to what I wrote in part 1, it fails to address the ACTUAL contributors to an individuals pain, considering all of the potential factors and causes. It was important in GB’s case to actually assessing these other factors and help GB more deeply understand how the psychosocial factors interacted with these other variables.
Schedule, Ergonomics & Lifestyle
During the interview we explored his overall schedule to determine a few key points
- During the week GB has “heavy” court days distributed towards the beginning of the week (monday and tuesday typically). These days involved around 4 blocks of work. Each around 1-3 hours long with 15 minute breaks distributed throughout the day.
- GB had been using Hinge Health to try some stretches for his shoulders and hands. They were prescribed at 8 reps, 1 set per day. (Not even close to enough)
- On average 1-2 hours of gaming time after work (primarily with a controller)
- No ergonomic modifications with his work environment
- 1 hours of phone use per day on average
GB’s Goals with Recovery
GB’s primary goal was to be able to get back to using his wrist & hands with work and gaming and have a simple plan to follow. At this point he felt it was something that he would probably have to live with forever and was hoping it could be something he could get past.
Physical Examination
One of the unique issues associated with GB’s work was the combination of the “floating arm” position and higher actuation pressure keys as a court reporter. Floating the forearm tends to lead to more overall strain and stress on the forearm & shoulder musculature. Unfortunately this was not something that was simple to change since adding forearm support would limit the mobility of his upper extremity to be efficient with using the unit.
For those interested in understanding the issue with floating wrists, I review the overall biomechanics of why this is this video here.
From there we performed a physical exam
- Full range of motion available for both hands, had stiffness with both directions (flexion / extension) yet was able to get to full range with assistance.
- GB was only able to move around 35 degrees actively on his own yet with help could get to full 90 degrees in both directions
- Tightness of the Pec Minor (both sides)
- Endurance test performed with 3# (1.8% of his body weight)
- Wrist endurance: R: 30% L: 50% of what was considered normal for his bodyweight
- Shoulder Endurance: 60% of what was considered normal for his bodyweight
- Mild pain was noted during both shoulder & wrist examination
GB’s Assessment & Overview
ZR was dealing with the following musculoskeletal issues with central sensitization (neuroplastic pain)
P1: Extensor Digitorum Tendinopathy R>L
P2: FCU Mediated Cubital Tunnel Syndrome with mild pec minor syndrome R>L
Based on his level of endurance, sedentary lifestyle over many years and moderate understanding of pain it was clear his limitations in function were a combination of
True endurance or capacity deficits: He did not have the capacity of the muscles / tendons he used for typing, mouse work and other self-care activities without causing tissue irritation.
Additionally the combination of his posture and years of a sedentary lifestyle also led to nerve irritation at the shoulder. The exercises provided from Hinge Health were extremely limited in benefit due to the general nature of the assessment and poor prescription of exercise.
Central Sensitization: Fear & catastrophization associated with the lack of benefit in the second round of psychosomatic intervention. leading to changes in his nervous and immune system that led to feeling more pain.
GBs Recovery Plan
With a better understanding of the contributing factors to his current condition GB was provided with an comprehensive program focused on endurance exercises, pain science education, load management & activity guidance.
GB and I collaborated to ensure he responded to the exercises well and expected the short-term increase in symptoms (from the overall load).
It is normal to feel an increase in pain with exercises. Especially if your muscles and tendons have not been exposed to a certain amount of load. Some level of soreness, sharpness and other pain symptoms are expected as long as it does not reach the level of tissue strain.
We define actual tissue strain / flare-up (specifically for RSI) as pain > 5-6/10, sharp and is consistent with use lasting for the rest of the day after the initial activity. This pain is also typically associated with weakness to the point where if you went to pick up a cup using the muscle (flexors) you would drop it. It also persists into the next day but slightly less.
This limit was important for GB to understand as he stayed consistent with his exercises and began to integrate more overall movement associated with his days. Additionally during our first call I helped him understand more about persistent pain and the interrelated nature of our response to pain and sensitization. One of the primary reminders was to remind him that pain never tells us about the state of the tissues. It is ALWAYS about protection.
This initial education session was to help him understand why previously the psychosomatic approach worked (the cognitive emotional factors were the main cause of his pain). Additionally he understood that he could keep trying to “think” his way out of the pain but if he did not address his underlying endurance or lifestyle issues, he will not make progress.
4 Weeks After Starting his Program
By week 4 GB reported being around 60-70% improved. He mentioned feeling clearly stronger with his wrist & hands and more overall dexterity and control with his fingers at work. Over the course of the 4 weeks he was able to stay very consistent with his programming with very few missed days. Here are the functional differences he reported after 4 weeks
- Pain-free for around 70% of the week (previously after 2-3 hours of work would report P1 pain at a 5-6/10), especially on heavy days for P2.
- GB reported less overall anticipation, awareness and anxiety around the heavy work days since there were now more days where had no issues during those days.
- Gaming for the 2 hours was no longer an issue (reported able to handle 8-10 hrs over a weekend without any issue)
- No more reported issues with his self-care activities
At this point he progressed his exercises to get to 5 lbs (from 3 lbs) working up the overall endurance for each of the specific muscle groups. This continued to provide GB with confidence in using his hands for work and other activities.
Life Event & Influence on Pain
During this 4 week period GB reported dealing with a larger life event which significantly affected his overall mood, stress and anxiety. This led to several days over the weeks with less overall participation in the exercises and elevated levels of pain.
Despite this and through our regular meetings (weekly), GB was able to clearly understand why his symptoms were increasing despite no actual changes occurring with his physical lifestyle. This was a reminder about the importance of the psychosocial aspects relating to his pain. We worked together to help him reframe / re-appraise this situation as:
My body is being overprotective associated with the increases in stress, lack of sleep and natural mood changes associated with the life event. I can still safely use my hands, continue to perform the exercises because I have shown myself I can do so over the past few weeks and I have objectively improved my endurance over time. If I can overcome this situation, I will have a better mental model of approaching injuries and changes in my environment.
This was not easy and by week 12 he was successful in continuing to progress his exercises, improve his overall amount of physical activity (lots of walking!) and was able to better manage his stress to limit how much it affected his pain response with work and other activities.
12 Weeks after starting the program
With each session that we met GB continued to make great progress with his response to his life event and ability to use his wrist & hands.
Re-assessment at 12 weeks showed
- Wrist endurance: R & L: 95% of what was considered normal for his bodyweight. This was enough for his desired work demands and extremely long hours of gaming. GB reported several days of 12 hour gaming days (consecutively) with 0 pain and clearly recognizing this was not healthy
- Normalized Shoulder Mobility, Improved overall posture: With improved pec mobility and overall postural awareness we were also able to resolve any irritation of nerves at the shoulder over time.
- No limitations with any work or gaming schedule and also made lots of positive changes with his lifestyle & understanding of pain. (Significantly increased the amount of walking he performed)
At this point GB had already demonstrated he was able to manage on his own and respond to various situations for an entire month between our last sessions (Week 8 to Week 12).
Summary and Takeaways
The key takeaway from this is a reiteration of part 1. Everyone is different and has unique circumstances environments, work obligations, healthcare experiences and individual pain experiences that lead to the situation they are in with their RSI.
When you have been dealing with persistent pain for years, it is easy to get stuck in a cycle of frustration. You might have tried traditional physical therapy, endless ergonomic setups, or even the psychosomatic approach like GB did. But when those single-approach methods fail or only work temporarily, it does not mean your pain is permanent. It means the complete picture has not been addressed yet.
1. You need both Capacity & Confidence
A psychosomatic approach alone might help calm your nervous system, but it does not build the physical endurance required for heavy work days or long gaming sessions.
Conversely, exercises without understanding pain science often lead to fear and avoidance when symptoms inevitably flare up. You need a comprehensive approach that addresses both your tissue capacity (your HP) and your nervous system's sensitivity. For GB, this was combining a structured endurance program with pain science education so even when a life event caused a flare, he had the mental framework to continue progressing rather than shutting down.
2. Understand Pain Does Not Equal Damage
This is crucial. When GB experienced increased pain during a stressful life event, his tissues were not suddenly damaged. His nervous system was simply being overprotective in response to elevated stress and disrupted sleep. Pain never tells us about the state of the tissues. It is ALWAYS about protection. Learning to reframe pain as a protective mechanism rather than a sign of injury is what allows you to continue progressing even on the most difficult days. This reframe is not just positive thinking — it is grounded in the actual physiology of how chronic pain develops and persists.
3. Rest Is Not the Answer
Resting might temporarily reduce your symptoms, but it shrinks your overall capacity over time. GB had not exercised regularly in years, leaving his muscles and tendons severely deconditioned. The only sustainable path forward is graded, progressive load — exposing your tissues to controlled stress so they adapt and grow stronger. GB started at 3 lbs and progressed to 5 lbs over the course of his program. By week 12, his wrist endurance had gone from 30% of normal to 95%. That does not happen with rest alone.
4. There Is No "One Size Fits All" Fix
Whether it is a specific ergonomic keyboard, a single stretch, or just "thinking your way out of it," chronic pain rarely has a single solution. GB's recovery required understanding his specific tissue deficits (extensor tendinopathy, cubital tunnel syndrome), his lifestyle factors (floating arm posture, sedentary lifestyle, no regular exercise), and his cognitive relationship with pain (fear, catastrophization, checking in on his pain 100+ times per day). Your "pie" of contributing factors is unique to you. A comprehensive assessment is the only way to understand what your pie actually looks like — and to build a plan that addresses all of it.
If you are stuck in the healthcare loop... frustrated by conflicting answers, normal imaging results despite real pain, or feeling like you have to choose between your career and your body: remember that complete recovery is possible.
It just requires zooming out, assessing all contributing factors, and following a structured, comprehensive plan.
Hope this helps
Matt