Pain-Free Mousing

When performing ergonomic assessments, the main factors that I have found that contribute to mousing pain include:

  • Mouse Positioning
  • Mouse Movement
  • Muscular Tension When Using the Mouse
  • Forearm Position

Here are some tips to help reduce your risk of developing a repetitive strain injury or tendinitis from mouse use.
MOUSE POSITIONING

Causes of Pain

  • Reaching forward for the mouse onto a desk that is higher than the keyboard.
  • Reaching for a mouse placed to the far side of the keyboard.

Tips for Preventing Pain

  • Position the mouse in a more comfortable and ergonomic location
    • Use an attachable mouse holder that adjusts to fit over numerical key pad (if you do not use the 10-key) or as closely to it as possible.
    • Or use a keyboard bridge over the numerical keys if you do not use the 10-key portion of the keyboard.
    • Or use a keyboard station such as the Contour Roller Pro which has a rollerbar mouse that is positioned immediately below the space bar of the keyboard.

MOUSE MOVEMENT

Causes of Pain

  • Excessive wrist or arm movement when activating the mouse.
  • Planting the wrist down and swiveling the mouse using wrist motion.
  • Planting the wrist down placing pressure against the carpal tunnel.
  • Bending the wrist backward (extended) when using the mouse.

Tips for Preventing Pain

  • The mouse should be at about the same level of the keyboard and positioned as closely to the keyboard as possible.
  • Avoid reaching forward, up, or out to the side when using the mouse. Position the mouse to avoid these movements (see mouse positioning tips).
  • Activate the mouse by using small movements from the shoulder and elbow muscles rather than the wrist muscles.

Ergonomics

  • Keep the shoulders relaxed.
  • The elbow should be held loosely at the side in a direct line under the shoulder.
  • The wrist should be held in a neutral position (not bent forward or back or angled to one side or the other).
  • Do not plant the wrist down on that desk or on a wrist rest. Glide the wrist over surfaces always maintaining the neutral position.

MUSCULAR TENSION WHEN USING THE MOUSE

Causes of Pain

  • Forcefully squeezing the mouse between the thumb and small finger.
  • Forcefully activating the mouse buttons or switches.

Tips for Preventing Pain

  • Hold the mouse as lightly as you can while still maintaining control.
  • Keep the fingers held loosely against buttons and switches, not floating tensely in the air.
  • Do not pound mouse buttons or forcefully squeeze switches. Use only the lightest force necessary to activate controls.
  • Using a wireless mouse can eliminate the tension of pulling against the cord (even these small tensions add up by the end of the day).
  • Use a mouse and mouse pad that can be switched easily from the right to the left hand to share the work load between the two hands.
  • A keyboard station such as the Contour Roller Pro that incorporates a rollerbar mouse eliminates the need to hold the mouse.
  • Research mousing options such as the NoHands foot-activated mouse or a head-activated mouse placed in a baseball cap.
  • Perform forearm and wrist stretches throughout the day.
  • Gently stretch the thumb into the hitch-hiking position.

FOREARM POSITIONING

Causes of Pain

  • The forearm rotated into the palm-down position for long periods of time.

Tips for Preventing Pain

  • Vertical mice are good choices as the hand shake position with the forearm neutral rather than palm down can relieve forearm stress.
  • Stretch into the palm-up position throughout the day.
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Scars

Scar tissue development is a natural and important part of the healing process.  A scar forms to repair the skin and other tissues that are damaged by trauma, burns or surgical incisions.  Without the process of scarring, wounds would not close.

Although some of the people that I treat in the clinic are concerned about the appearance of their scars, I find that the majority who attend hand therapy don’t seem to be.  In fact, surprisingly, the scar is often considered to be a badge of honor, a tribute to the injury that was overcome. So, if scarring is a natural process and improved appearance is not a concern, why is it important to address scarring in injuries or after a surgery?

Our skin and the tissues underneath it (fascia, tendons, nerves) are arranged in layers that slide and glide on each other.  When a scar forms, the body does not differentiate these layers of tissue but lays down collagen to fill in the wound – binding all the tissues together.  This binding can lead to loss of full motion; to a feeling of stiffness even if motion is fully restored; and to pain as tissues that normally slide smoothly on and around each other begin tugging and creating friction..

Try this activity:

  1. Fully straighten the fingers of your left hand and look at the skin on the back of your hand.  The skin is loose and you will be able to see small wrinkles.
  2. Now, make a fist with your left hand.  Pay attention to how the hand feels while making that fist.  You should be able to make a fist easily (assuming you have not had an injury).  Observe how the skin tightens over the back of the hand and the wrinkles disappear for the most part when your hand is positioned in a full fist..
  3. Now, open the hand again.  Place your right fingers over the back of the left hand with some firm (but not painful) pressure.  Attempt to make a fist with the left hand while maintaining the pressure against the back of the hand with the right fingers.  Do you notice a difference in the effort that it takes to attempt to make a fist as the tissues are prevented from sliding over each other?
  4. Open the hand again.  Now, actually push the skin towards the wrist with the right fingers as you attempt to make a fist with the left hand.  Can you feel the stress of the movement translated even into the tips of the fingers?

This demonstrates the effect of an outside force impeding the normal sliding of tissues during movement.

So, what can we do to limit the effect of the scar formation on the surrounding tissues?

  • Massage the scar – 2-3X a day for 2-3 minutes each session.
    • Perform small circles over the scar.
    • Place your fingers just to the side of the scar and push into the scar tightness.  Repeat in the opposite direction.  Repeat along the length of the scar.
    • Try to lift or roll the scar up from the tissues underneath it.
    • Do not rub the scar vigorously.  This creates friction and can cause blistering in a new scar.
    • Do not separate the sides of the scar or pull the scar to widen it.

scar massage

  • Provide compression over the scar with gloves or sleeves or a scar mold provided by a therapist.

finger sleevejuzo_gloves

  • Use silicone gel pads over the scar at night.

silicone get

  • Perform range of motion exercises as able (depending upon any precautions related to the type of injury) so that the scar is lengthening during the healing phase.

If the scar continues to cause pain or problems after its natural remodeling phase, there may be other medical options to minimize the effect of the scar including laser treatments, corticosteroid injections, and surgical removal.

 

A Quick Comparison of Carpal, Cubital and Radial Tunnel Nerve Compressions

Three peripheral nerves provide power and sensation to the hand and arm.  The following is a quick comparison of the most common sources of pain caused by compression syndromes of these nerves.

nerve paths

Carpal Tunnel Syndrome

  • Nerve Affected:  Median
  • Location of Compression:   Wrist
  • Numbness and/or Tingling:  Usually in the Thumb, Index, Middle & Half of Ring Fingers
  • Pain:
    • Usually in the Thumb, Index & Middle Fingers
    • A band of pain around the wrist
    • Pain in the muscles at the base of the thumb
    • Pain radiates up the forearm
  • Likely Cause (activity related):
    • Frequent gripping/squeezing/holding of tools
    • Gripping or pinching tools or objects for a period of time
    • Finger movement with the wrist held at an awkward angle
  • Prevention:
    • Avoid sustained or repetitive grip and pinch
    • Maintain the wrist in a neutral (straight) position with activity
    • Avoid leaning on or putting pressure against the front of the wrist of the base of the hand
  • Splinting:   A wrist brace that  holds the wrist in the neutral (straight) position at night

Cubital Tunnel Syndrome

  • Nerve Affected:  Ulnar
  • Location of Compression:   Elbow
  • Numbness and/or Tingling:  Usually in the Ring & Small Fingers
  • Pain:
    • Usually in the Ring & Small Fingers
    • Pain in the hand muscles on the small finger side of the hand
    • Pain radiates up the forearm and into the elbow along the small finger side
  • Likely Cause:
    • Leaning on the elbow or pressure against the forearm along the small finger border
    • Frequently bending and straightening the elbow, such as when pulling a lever
    • Holding the elbow bent for long periods of time, such as when sleeping or holding a phone to the ear
    • Forceful elbow extension (straightening) activities, such as rowing, gym activity, push-ups
  • Prevention:
    • Avoid leaning on the elbow or putting pressure on the forearm muscles
    • Avoid holding the elbow bent more than 90 degrees for any length of time
    • Avoid repetitively bending and straightening the elbow
    • Avoid repetitive or forceful elbow extension activities
  • Splinting:   A soft pad or elbow support that holds the elbow in a mostly straight position at night

Radial Tunnel Syndrome

  • Nerve Affected:  Radial
  • Location of Compression:   Muscles on the back of the forearm near the elbow
  • Numbness and/or Tingling:  Uncommon
  • Pain:
    • Usually in the elbow and forearm muscles
    • Pain may radiate down the arm into the wrist and the back of the hand
    • Pain may radiate up the arm towards the shoulder
  • Likely Cause:
    • Computer mouse activity, swiveling the wrist and forceful mouse “clicking”
    • Holding the fingers tensely extended over the computer keyboard
    • Forcefully bending the wrist forward and back
    • Repetitive twisting movements, such as when using a screwdriver
    • Carrying or lifting heavy objects, particularly with the forearm pronated (palm rotated down)
  • Prevention:
    • Maintain the wrist in a neutral position while using the computer mouse
    • Don’t hit the keys or click the mouse forcefully and keep the fingers relaxed over the keys and mouse
    • Avoid repetitive and forceful wrist movements or twisting movements
    • Avoid heavy lifting, especially with the palm facing down, such as carrying a suitcase or heavy briefcase
  • Splinting:   A wrist splint that holds the wrist neutral may be helpful when performing stressful activities

Radial Tunnel Syndrome

As a certified hand therapist, I often treat people suffering from the symptoms of carpal tunnel syndrome (CTS). A less commonly known injury, but one that we are seeing more frequently in the clinic, is Radial Tunnel Syndrome (RTS). If you are experiencing an aching or burning sensation in the back of the forearm or over the back of the wrist or hand, you may have symptoms of RTS rather than CTS.

Anatomy

The radial nerve is one of three main peripheral nerves that provide sensation and power to the arm and hand (the other two are the median nerve and the ulnar nerve). The radial nerve leaves the spinal cord at the neck and travels down the arm and into the back side of the forearm. In the forearm it passes through the supinator muscle, the muscle that turns the palm up (such as when using a screwdriver).

The radial nerve is responsible for providing sensation to the back side of the forearm and the back of the hand. It is also responsible for providing power to the muscles that pull the wrist back and straighten the fingers at the large knuckle joint.

Causes of Radial Tunnel Syndrome

As the nerve travels down the arm, repetitive or forceful movements can cause friction at several sites along the nerve pathway as it passes through muscles and ligament bridges. Repetitive or forceful movements can also cause swelling in the tissues that surround the nerve. This compresses the nerve, pinching it and causing sensations of aching, burning, numbness and tingling.

Symptoms of Radial Tunnel Syndrome

Symptoms of RTS include an aching or burning pain over the back side of the forearm and/or into the back of the wrist. There may be tenderness over the back of the elbow and forearm close to the elbow. Pain may become worse with activities that require a lot of wrist movement (such as manipulating the mouse), finger movement (such as clicking the mouse), and palm up movements (such as using a screwdriver). With pressure against the tender area close to the elbow, you may experience a tingling or radiating pain. The arm may feel tired and heavy.  An aching pain may radiate down the arm into the hand or up into the shoulder.  The back of the hand, the index finger knuckle, and the muscular space between the index finger and the thumb may feel swollen.

Things to Help Prevent and Control Pain from RTS

If you are experiencing symptoms of RTS, here are a few things you might try to help you reverse the symptoms.

  • Rest as best as you can from the activities that are causing the problem.
  • A vertical mouse that places the forearm in a neutral position (the “handshake” position) may be helpful.
  • Do not swivel the mouse with wrist movement.
    • Keep the wrist neutral (straight and level, not bent forward or back or angled to either side) when typing and using the mouse.
    • Control the mouse by using the larger shoulder and elbow muscles to move it.
  • Keep the fingers relaxed on the keyboard and mouse.
    • Don’t forcefully straighten or lift the fingers while typing or clicking.
    • Use the least amount of pressure necessary to activate the keyboard and control the mouse.
  • Use a wrist brace to limit wrist movement and to help keep the muscles of the forearm relaxed.
  • Take frequent micro-breaks.
  • Use cold packs and hot packs.
    • A cold pack placed over the forearm muscles several times a day can help control swelling from overuse.
    • Hot packs can help improve flexibility.
    • Both can temporarily relieve pain.
  • Gently stretch the forearm muscles.
  • Avoid the following:
    • Heavy lift, grip or activities that twist the forearm.
    • Using a screwdriver   (Use electric tools whenever possible.)
    • Picking up luggage.
    • Weight-lifting.
  • Be careful of using tennis elbow straps that can place additional pressure on the radial nerve.
  • Seek medical attention if symptoms do not rapidly improve.

RTS is often confused with tennis elbow. Tennis elbow is an inflammation of the tendons as they attach on to the lateral epicondyle (the bony bump on the outside edge of the elbow). The tenderness associated with RTS is often a few inches farther down the forearm, more on the muscle than on the bone. A tendinitis pain is often sharper with activity and, unless it is a severe case, lessens with rest. Nerve pain, such as with RTS, can be more of an aching, burning pain that may become more severe after activity or at night. When seeking medical attention, be specific with your description of symptoms so that you can help your doctor diagnose the problem accurately.

What Exactly Is Occupational Therapy?

While watching a special on CNN last week about the future rehabilitation needs of the Boston Marathon Bombing victims, a beautiful segment was aired that showed occupational therapy at it’s finest.  This program section followed the recovery of a gentleman with a lower extremity amputation caused during an industrial accident.  His return to functional independence was emphasized through balance activities as he performed basic daily and work activities (making coffee and a shoveling-simulation task).

Unfortunately, the segment did not specify that the activities being performed were directed by an occupational therapist.  The general term “therapy” was used, and physical therapy was implied.  But the process certainly felt like an occupational therapy intervention.  Was this an oversight by CNN?  I certainly don’t think so.  But why, as happens too frequently, did occupational therapy hide in the shadows?  My thoughts:  name confusion; a professional philosophy that is difficult to describe in just a few, simple words; and the ever increasing demands of the healthcare industry.

So, what exactly is occupational therapy?  Is it fine motor control (occupational therapy) versus gross motor control (physical therapy). Or is it upper extremity rehab (arms = occupational therapy) versus lower extremity rehab (legs = physical therapy).  These are quick, easy explanations, but certainly not thorough and sets up for division of therapy efforts versus collaboration.

The roots of occupational therapy go back to World War I.  At that time, there was a large demand for the rehabilitation of injured soldiers returning home.  Rather than focusing on only the physical component of injuries,  the nearly 148,000 soldiers admitted to hospitals between 1917 and 1920 were treated with a holistic approach by “reconstruction aides” who borrowed from the fields of nursing, psychiatry, rehabilitation, self-care, and social work.  This whole-body, activity-focused and client-cenered treatment encouraged the patient to take an active roll in his recovery and used purposeful activity to enhance the rehab experience.  By 1920, the field of occupational therapy was officially founded.

Fast-forward to the 21st century, the term “occupation” is now essentially synonymous with work activity.  It’s not unusual for a client to arrive at the clinic and ask: “Are you going to get me a job?”;  or “I’m 78 years old. Why is the doctor sending me to occupational therapy?  I’m not going to go back to work.”  Historically, however, the term “occupation” meant any purposeful activity in the triad of self-care, leisure and work demands that occupied our time.

This historic definition of the term “occupation” is the basis of the occupational therapy philosophy to treatment.  It is what sets us apart from the profession of physical therapy.  Traditionally, physical therapists focus on strength and motion, on the biomechanics of an injury.  As an occupational therapist focusing on the rehabilitation of hand injuries, I borrow from those techniques.  Certainly, the physical recovery of an injury is an essential component of hand rehabilitation.  But the purpose is not just to gain motion and strength.  It goes beyond that.  The following quote, attributed to Mary Reilly, appears on the website for the American Society of Hand Therapists – “…man, through the use of his hands, as they are energized by mind and will, can influence the state of his own health”.

The American Occupational Therapy Association states: “Occupational therapy practitioners bring an added dimension to this [hand therapy] specialty area.  They use an occupation-based and client-centered approach that identifies the participation needs of the client –  what he or she wants to be able to do in daily life that is fulfilling and meaningful – and emphasizes the performance of desired activities as the primary goal of therapy.”  The ultimate goal of occupational therapy is to preserve life roles and habits; to promote a sense of normalcy and psychological well-being during day-to-day functioning; and to make the client a partner in his or her rehabilitation rather than a passive participant.

86% of certified hand therapist are occupational therapists and only 14% are physical therapists.  Yet, the majority of clients attending hand therapy believe that they are receiving physical therapy.  To be honest, each of our professions has benefitted from using techniques from the other.  But I have a terrible confession to make – when I overhear someone on their phone telling their ride to pick them up from physical therapy in 10 minutes, I don’t always correct them.  It’s not that I’m not proud of being an occupational therapist, or that I’m a wanna-be physical therapist.  The truth of the matter is, healthcare providers are struggling to provide quality care with an increased demand for treating a larger caseload, more documentation requirements, and less financial reimbursement.  As awful as it may be, there are times when I have to choose between educating my client about the philosophical difference between OT and PT and providing practical information on scar management, control of swelling, and home exercises. And that is why occupational therapy stays hidden in the shadows rather than taking it’s place in the spotlight.

Yet, occupational therapist should be proud of what they do and of the many people they help to recover from injuries that can threaten well-being as well as physical function.  Some common examples of role disruption that we might see in the clinic include:  a child who is having difficulty with the role of student as fine motor deficits impair his or her writing skills; a young lady who is having difficulty with the role as a mother as “new mom’s tendinitis” impairs her ability to care for her baby; a graduate student who is having difficulty with the role as lab assistant as a snow board fracture impairs his ability to fill pipettes in a science lab; a baby boomer who is having difficulty with the role as wage earner as carpal tunnel syndrome impairs her ability to use a computer keyboard; a retiree who is having difficulty with the role as a volunteer as arthritis impedes his ability to make a full fist. Practically speaking, the occupational therapist looks at these life roles, assesses the amount of dysfunction the injury or illness is causing, and promotes healing through injury recovery or activity modification.   According to the University of Southern California’s Occupational Therapy Program: “no matter what injury, illness, condition, disability, lifestyle, or environment stands in the way, occupational therapists help people to perform, modify, or adapt their skills and activities in order to live healthier, happier, and more productive lives.

So, go live life to the fullest!  Marji

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What is Cubital Tunnel Syndrome?

Everyone has now heard of carpal tunnel syndrome. The term is seen in everyday magazines, is used commonly in texts and tweets, and is even the name of a musical group. Carpal tunnel syndrome is the most commonly occurring nerve compression of the upper extremity. It is caused by the median nerve becoming pinched at the wrist causing numbness in the thumb, index finger, middle finger, and partially in the ring finger. It can cause weakness in the muscles at the base of the thumb and cause pain that radiates up the arm into the shoulder and neck. Like the older sibling who gets blamed for all wrong-doing, carpal tunnel syndrome has become synonymous with all hand pain.

Lurking in the shadow of carpal tunnel syndrome’s fame is its counterpart, cubital tunnel syndrome. Cubital tunnel syndrome is the second most commonly occurring nerve compression of the upper extremity. It is caused when the ulnar nerve, running parallel to the median nerve in the forearm, becomes pinched at the elbow. When you hit your “funny bone”, you are actually hitting this nerve. The ulnar nerve is responsible for sensation in the small finger and partially in the ring finger. Trauma to the ulnar nerve can cause pain in the small finger side of the hand that radiates into the forearm towards the inside of the elbow. It can cause weakness to the small muscles in the hand and, if severe, loss of coordination.

It is time to bring cubital tunnel syndrome out from behind carpal tunnel syndrome’s shadow. If diagnosed correctly, there are simple modifications that can be made to help relieve the symptoms of this frequently overlooked nerve compression.

  • Avoid bending the elbow for any length of time. This stretches the nerve tautly through the cubital tunnel. Activities that can irritate the nerve and simple solutions include:
    • sleeping with the elbow bent – use pillows for support; wrap an ace wrap or towel loosely around the elbow to keep it from bending; avoid sleeping on the arm or sleeping with the hands positioned up behind the head.
    • holding a phone to the ear – use a head-set.
    • blow-drying hair.
    • driving – adjust the seat position so that the elbows are open and relaxed; avoid resting the arms on the elbow supports or window sill.
    • computer work – position the height of the keyboard and mouse so that the elbows are open a bit more than 90 degrees.
    • playing the guitar (because of the positioning of the fretting hand) – warm-up prior to playing, take frequent breaks, stretch often. 
  • Don’t lean on the elbow.
  • Don’t lean on the forearm, especially if it is placed over the hard edge of a desk or table. Place a soft support or cushioning under the forearm.
  • Position the mouse and the keyboard in front of you so that you do not need to reach forward or out to activate them.
  • The mouse and keyboard should be low enough that the shoulders are relaxed.
  • Activate the mouse by keeping the wrist solid and using shoulder movement for positioning.
  • Keep the wrists neutral. The wrists should be flat over the keyboard, not bent forward or back. The wrists should not be angled towards the small finger while typing. Using a split keyboard or a vertical mouse may help position the wrists correctly and relieve tension in the forearms.
  • Avoid repetitive elbow bending and straightening.
  • Avoid over-developing the triceps during gym and sports activities.

As with other injuries, it is important to:

  • take frequent breaks when performing repetitive work.
  • gently stretch the forearm muscles.
  • warm-up prior to performing strenuous activity.
  • avoid or modify activities that cause pain.
  • use cold packs to control post-activity pain when necessary.

Need more information?  Or want to share your experiences or ask questions of our community?  Visit us online at HandHealthResources.com or via our Facebook or Twitter accounts.

Let’s put some caring back into healthcare!  Marji

 

mHealth – Using Mobile Devices to Improve Healthcare

What an amazing time we are living in! With an internet search and the click of a button, we have more access than ever before to even the most obscure information. With the current rapid changes in technology, we are seeing a trend towards people seeking answers to their healthcare questions online as well as through mobile devices. These emerging tools are allowing us to take charge of our healthcare in ways never before possible.

In fact, I just came across a new term that I think we will be hearing much of in the near future: mHealth. mHealth was defined by a National Institutes of Health Consensus group as the use of mobile and wireless devices to improve health outcomes, healthcare services and health research.

My goal, as an Occupational Therapist and a Certified Hand Therapist, is to provide you with reliable and helpful tips that will ease your recovery from a hand or upper extremity injury. Social Media is making this much easier than ever before. Here is how I will attempt to organize my information using mHealth:

  • Through this weekly blog (handtherapy.wordpress.com)
  • Through daily Tweets @handhajic. As a loose guideline, the tweets will be organized as follows ( but I’m sure we will throw in some random, off topic tweets as well!):
    • Medical Monday – information relating to specific hand injuries
    • Open Topic Tuesday -answers to questions generated by our followers
    • Workday Wednesday – ergonomic suggestions to help make your work activities more comfortable and less stressful
    • Therapy Thursday – tips, tricks, and advice from the clinic
    • Fun Fact Friday – interesting facts about our hands and arms; or just fun facts in general!
    • Weekend Warriors – tips to help you protect your hands from sports, gardening, home projects and leisure activities
  • Through our Facebook page – another way for you to keep in touch with the clinic. I will post my own commentary; provide injury and recovery information; give you behind-the-scenes glimpses into an active, outpatient occupational therapy clinic specializing in upper extremity rehab;; and throw in some general information about the profession of occupational therapy. Look for our logo and “Like” us at the Hand Therapy & Occupational Fitness Center.
  • HandHealthResources.com – our website is currently in the process of being updated for content and ease of use. However, it is still full of information on upper extremity injuries, recovery/therapy, ergonomics and prevention tips. Feel free to browse.

What will make this endeavor successful are the questions and feedback that will come from our followers. Please don’t be shy. My clinical experience leads me to believe that the healing process is fostered with a sense of community as people relate their experiences, frustrations and triumphs with each other as they travel on the road to recovery. So, share your journey. Ask your questions. Seek and/or provide support.

And, as always, let’s put some caring back into healthcare! Marji