Ergonomics: Not Just for Adults

Ergonomics: Not Just for Adults

Parents help ease the transition from summer fun to school routine.  Just as important (but perhaps not quite as much fun) as shopping for the right back-to-school fashion, parents can encourage positive health and ergonomic practices that reduce their children’s risk for developing repetitive strain injuries.

Several years ago, a youngster was referred to our hand therapy clinic with classic and debilitating symptoms of Carpal Tunnel Syndrome (CTS).  However, the physician, a generalist, was adamant that this young person did not have CTS as “16 year-olds do not develop these types of injuries”.  This patient’s parents sought a second opinion.  The patient was officially diagnosed with CTS upon physical examination with an orthopedic hand surgeon and nerve conduction examination, subsequently underwent surgical decompression of the nerve, and had a very successful recovery.

It is true that we don’t see many pre-teens and teenagers with symptoms of repetitive stress injury.   The flexibility and rapid healing rate of children allow them to get away with much more than adults when it comes to the repetitive and forceful nature and awkward postures of physical activity that create symptoms.

Unfortunately, the increasing role of technology in our lives, across all age groups, can not be ignored.  And formal classes in typing technique, posture and ergonomics are no longer offered in school as children begin using technology in their toddler years rather than learning to type in high school.  It is important for adults to be aware of the risk factors and to teach good ergonomic principles and work practices to our children in order to help keep the next generation pain-free.

Kids, Computers & Repetitive Strain Injuries (RSIs)

  • In a series of international studies, up to 60% of students across the globe reported eye-strain, neck & shoulder pain, wrist and back discomfort, headaches and fatigue. Symptoms were reported in children as young as in 4th grade.Repetitive strain injuries in children are highly correlated with the repetitive, awkward and prolonged postures they are using when they are working on computers or laptops.
  • Most computer stations are designed for adults or lack the adjustability needed for children who display a wide range of body sizes and body growth rates.
  • The portability of technology (e.g. laptop computers, video game players, mobile phones, iPads) allow for use in non-traditional settings and with non-traditional postures (for example, slouched in a couch or lying on a floor) that can increase the risk of injury.

General Guidelines to Promote Healthy Computing

  • Provide children the skills to understand what is good for their bodies so they can make good choices for themselves.
  • Teach healthy computer habits which can be carried into adulthood.
  • Encourage physical activity. Children who exercised during breaks from computer use had fewer pain complaints then those who were sedentary.
  • Encourage healthy habits including drinking plenty of water for tissue hydration and eating a variety of nutritious foods.

Computer Comfort & Ergonomics for Children

  • Chairs should be adjustable allowing for easy changes for growing children or for various family members of different ages and sizes.
  • The best chairs should have adjustability for chair seat height and depth. The back of the chair (providing lumbar support) should be able to be pushed forward. If the chair is not adjustable, use pillows or cushions to raise the child to the appropriate height or to support the back.
  • Position the child so that the eyes are level with the top of the monitor screen. The monitor should be placed directly in front of the child at about an arm’s distance away (about 12-14 inches) to prevent eye and neck strain.
  • Shorter legs should be supported on a footrest, sturdy box, or stack of stable books with hips, knees and ankles at about 90 degrees. There should be about 2 inches of clearance between the back of the child’s knee and the chair seat edge.
  • Increase type font on the monitor so that it is clearly visible to the child so they don’t have to squint or lean forward to read the screen. The screen should be clean and the brightness and contrast adjusted for easiest reading.
  • Reduce screen glare by placing the computer perpendicular to windows, having good room and task lighting, and, if necessary, using an anti-glare screen.
  • Teach your child to look away from the screen after every 15 minutes or so of typing to ease eye-strain.
  • Lower or remove chair arm rests so that child’s arms are loosely held at the side of the body, elbows bent at about 90 degrees, and the shoulders relaxed.
  • Place the keyboard and mouse within easy reach of the child so they do not have to stretch the arms out to use them.
  • Wrists should be flat and straight (in the neutral position) with fingers relaxed.
  • Teach the child to use the lightest touch possible on the keyboard.
  • Encourage the child to sit upright and not to twist, slouch or crouch in the chair while typing.
  • Encourage a typing break of 5-10 minutes for every 30-40 minutes of typing. Preferably the break activity should be active. A timer can be used to help the child learn to monitor himself.
A Parody of Holiday Decorating – with Safety Tips

A Parody of Holiday Decorating – with Safety Tips

Twas the week before Christmas
And all through the town
Holiday decorations were popping
up all around

Lights to be hung!
Tinsel galore!
All those boxes from storage
I stacked on the floor

To the desk chair I flew
Must have been such a sight
As I scrambled on top
To hang those bright lights

As I stood on my tiptoes
Oh! That rolling desk chair
It slipped! and I flew!
Should have been more aware

And as I was falling
And landing (real hard)
I spied another option
Outside in the yard

And so out I ran
Forgot all that clutter
And tripped in my hurry…
Such words did I mutter!

Got untangled from tinsel
Just to stumble and sprawl
Into those ornament boxes
Out of which I slowly crawled

Gradually worked my way over
Closer to the shed
But the pathway was blocked!
and I had nowhere to tread

Pushed and pulled all those boxes
Out of the way
Ouch…Twisted my back!
“Lumbar Sprain” Doc would say

But then what to my wondering
Eyes finally appeared
A ladder with safety labels
(Which I promptly ignored..having no fear)

The spirits had cheered me
And tasted ever so good
I was feeling kind of tipsy
Certainly not being as safe as I should

So, I climbed to the tip
To the very top rung
Carrying those decorations up the ladder
That needed to be hung

And finally, just had one
final bling to be placed
Thought I could..reach….the……top
This job would be aced!

But I reached too far over
And fell off the ladder
And on the way down
Made such a clatter

The neighbors all ran
To see the damage I had done
And as the ambulance drove off
I missed the cookie party fun.

Injury statistics are reported
And now I am one
Unfortunately for me
The joyful season is done

In my sad story
A lesson can be learned
Benefit from my mistakes
And healthy redemption be earned

This holiday time
Be safe when you decorate
And use common sense
Or share the same fate

Be careful this season
Follow those safety rules
Have Happy Holidays
And choose the right tools!

Be safe!… I proclaim
When decorating at heights
Remember ergonomics and
Have a healthy Christmas night!

According to the Center for Disease Control and Prevention (CDC), 8,700 people were treated in emergency departments in 2002 specifically for decoration-related ladder injuries. Don’t become a statistic this year. Follow these tips for a healthy and happy holiday season.

As you hang lights and decorations, use a step-stool rather than furniture for items that are slightly out of reach. Never stand on any furniture that is not stable. Make sure that the stool is locked into the open position. For higher tasks, use a ladder that is in good condition. For every 4 feet that the ladder reaches up, the base should be 1 foot away from the wall. Follow all height and weight restrictions that are posted on the ladder. Do not climb above the maximum height posted. The ladder top should extend 3 feet above the surface you are trying to reach. When climbing the ladder, face it directly. Keep balanced over the middle of the ladder. Do not overextend your reach. Place the legs on a solid and level surface. If the ground is soft or uneven, use a plank of wood to provide stability.

Use proper body mechanics to avoid back pain when lifting boxes. Ask for help when lifting heavier objects. Hold objects close to the body, not at arm’s length. Do not lean forward at the hips when picking up items from low surfaces; rather, squat down, hold the item close, and use the strength of your legs as you stand up to lift the item. Do not twist or turn at the waist. Your toes should always face the surface that you are lifting the object from or placing it on.

Avoid excessive clutter that can cause you to trip. Place electrical cords away from general walking pathways or tape them down. Do not overload electrical circuits. Keep walkways clear of boxes and decorations. Avoid rushing through the holidays. Perform activities requiring the most safety awareness when you are alert and relaxed.

Be safe!  Be Healthy!  Happy Holidays!

Cheers, Marji

How to host Thanksgiving Dinner with a Hand Injury

How to host Thanksgiving Dinner with a Hand Injury

The American Society for Surgery of the Hand has published some good tips on avoiding a hand injury while preparing your Thanksgiving meal (; Turkey Carving Safety). But…. what if you already have hand pain from a tendinitis, or arthritis, or carpal tunnel syndrome, or a recent hand or wrist sprain/fracture/injury?  Anticipating a full day of hand intensive activity when you are already in pain can be intimidating and anxiety-producing. Here are some survival tips to help those with hand injuries host the big event  without increasing pain. 

  1. Ask for help. Although this seems like common sense, it is often hard for a host to request help from his or her guests.  However, most family and friends would be more than happy to lend (a literal) hand. And don’t some of the best holiday moments actually take place in the steamy, fragrant kitchen?  Generate a party atmosphere -sipping something bubbly while chatting and sneaking food tastes- all while sharing the tasks of chopping, stirring and dish washing. Enlist someone who is strong and injury-free to lift the turkey out of the oven or perform the turkey carving. When someone offers to help with the dishes, accept gracefully. 
  2. Cut corners.  Less work=less hand stress=less pain. Thanksgiving should be about enjoying time with family and friends.  However, often Thanksgiving becomes all about the food. Large quantities of food. So much food, that we are obligated to overeat.  Be creative in finding ways to minimize the amount of work you actually need to do. Would anyone really be heart-broken if there were  fewer dishes on the table (as long as Mom’s famous stuffing is front and center)? Would anyone know if you used onions that were purchased already chopped?   Or if that apple pie was made from pre-sliced apples and prepared pie dough? Or, better yet, bought at a local bakery?  How about throwing tradition out for one year and planning a potluck?  Or purchasing a packaged dinner from the grocery store?  Could you use bottled gravy?   Can the butcher pre-cut the turkey so that smaller and lighter pans can be used for cooking?  Or, if it’s a small gathering, how about purchasing a turkey breast rather than the whole beast?
  3. Preparation is key. Plan ahead so hand intensive and possibly pain producing activities can be spaced out.  Design a menu that allows you to perform some early meal preparation over the 2-3 days preceding the holiday. Include house cleaning tasks and preparation into your Thanksgiving plan as well.  Perform heavier activities early in the week and complete only 1-2 a day.  The more you can pace your activities, the less physical and emotional stress on Thanksgiving day. 
  4. Gadgetize.  Dust off those kitchen tools. Use food processors, electric can and bottle openers, even an electric knife to reduce physical stress on the hands. 
  5. Minimize.  Ease stress on the body by following some general principles of joint protection and energy conservation: use leverage rather than grip (such as those “Y” shaped bottle openers); push rather than pull; slide rather than lift (use a dish towel on the counter to slide heavier pots and pans closer to the stove so you don’t have as far to carry them); use comfortably bigger and cushioned handles (the Oxo kitchen tool line is a good example). 
  6. Be practically festive.  Bring in some holiday cheer with a themed paper tablecloth and napkins (less laundry) and sturdy, decorative paper plates and paper or plastic glasses and stemware (fewer dishes). 
  7. Take time to care for yourself.  If, in spite of all your preparation and planning, your hands are more painful or swollen by the end of the day, sit for a few minutes, put your feet up and apply a cold pack.   Perform only the most necessary clean up. And aim to have a relaxing day the following day. Intending on carrying a bunch of shopping bags on Black Friday?….although fun, perhaps not the best timing for the hands.  

Wishing you and yours a healthy and happy Thanksgiving. 

Best, Marji

Hand Therapy & the “No Pain, No Gain” Fallacy

Even after many years of practicing as an occupational therapist specializing in hand and upper extremity rehabilitation, I’m continually surprised when our clients arrive at their initial visit assuming that therapists will cause them pain.  Before I even sit down with them for the first time, clients may already in a state of emotional distress that interferes with the therapeutic process: overly medicated with either prescription or non-prescription drugs or alcohol; overly angry or anxious or tearful; or with an entourage of friends and relatives and significant others surrounding them for support and protection.

Each time this happens, I tell myself that I shouldn’t be too shocked as our culture does tend to support the philosophies of “No Pain, No Gain” and “More is Always Better”.   And our clients’ reports of previous encounters with healthcare personnel demonstrate that these philosophies are alive and thriving in our medical community.  One common complaint I hear is of experiences with heavy-handed therapists resulting in physical bruising and actual nausea-inducing pain.  Several clients have shared discussions they have had with a physician who instructs them to wear splints that stretch a stiff joint “to the point that it brings you to tears”.   And recently, I’ve heard reports of a physician assistant who tells patients with repetitive strain injuries that they should have more pain following an exercise session or they are not performing the exercises correctly. 

To be fair, some joints do require a more forceful approach as do more established joint contractures.  Patients undergoing therapy for knee and shoulder injuries will often joke of seeing their physical or occupational “terrorist”.  But these joints often tolerate the trauma and the swelling caused by an aggressive approach much better than the hand does.  The hand has so many structures that are so perfectly aligned that any increase in trauma or swelling seems to impact the perfect balance of function.

I won’t lie and say that hand therapy is or should be completely pain-free.  As much as we don’t like pain, it does serve a purpose: pain serves as a warning system that something is wrong; pain helps us know how far to push our limits; pain encourages us to rest an injured body part for healing purposes.  As therapists, we are often dealing with recent injuries, wounds, swelling, trauma.  We often see people within the first few weeks of an injury.  Occasionally we will see people the day after a surgery.  In our quest to establish the best possible outcome for recovery, we may have clients performing activities or exercises in a controlled way that may intuitively seem wrong (yet we know will not compromise healing).  So it is normal that we do treat people who are in pain.  However, our goal with therapy should be to minimize and control pain while promoting healing.

If my expectation and purpose with therapy is to ignore or to actually promote pain, I will likely find that my treatment backfires.  If I’m “cranking” on a swollen and recently injured joint, I’m going to potentially create more stress to the injury, create more swelling, generate more scar formation, possibly promote a pain-syndrome that goes beyond the bounds of a normal pain response for that particular injury.  If a tendon is inflamed from overwork or a nerve is compressed and I have someone exercise to the point of pain, I’ve done nothing but further the damage by increasing stress on tissues that were already breaking down.

In my opinion, a program of gentle persistence will always trump aggression.  And we have good results following this philosophy.  For example, take a stiff joint to the end of the range of motion and then nudge into the tightness; perform that motion for 2-3 minutes every hour and you will create tissue change without creating an increase in physical stress to the injured structures.  When wearing a splint to stretch a tight joint, going for a lighter tension for a longer period of time will yield results more effectively than than a short, painful stretch.  And when dealing with inflamed tissues, performing gentle stretches and nerve glides for the irritated tissues while promoting muscular balance by exercising the opposing muscle groups and strengthening postural muscles will promote healing.

In spite of common belief, hand therapy does not necessarily need to be painful.  Hand therapists should not be feared.  We can achieve good results in the clinic with persistence rather than aggressiveness.  The relief people feel is palpable when they realize that we are here to listen, collaborate, sympathize, share and educate rather than to “crank” on them.

Happy New Year! (In Spite of PQRS)

Happy New Year to all of our social media friends!  I took the holiday time to clean and organize the clinic.  It always feels good to go into the new year feeling prepared.  I wish all of our Facebook and Twitter followers a year of health, adventure, learning, and good memories.

One issue I dealt with over the weekend was the pending PQRS (Physican Quality Reporting System) changes required by Medicare as of January 1, 2015.  In March, we switched from paper charts to an electronic medical record system.  I am so glad that we did.  I can not imagine how a paper chart could ever fulfill Medicare’s document requirements at this time.   (Thank you, WebPT, for guiding us through this and making the charting manageable!)

In an attempt to improve quality of care, Medicare is now requiring that all of our patient encounters address nine aspects of care (the PQRS measures that pertain to occupational therapy).  This is a huge change from the three that were required last year.  While I certainly agree that quality of care can be enhanced by addressing such medical issues as obesity, alcohol abuse, nicotine use, depression, risk of falls and elder abuse, I do question whether an outpatient occupational therapy clinic focused on upper extremity rehabilitation is the correct place to bring up some of these issues.

Our hand therapy clinic is not the first line of defense in medical care.  By the time our patients reach us, they have had possible encounters with ER or urgent care personnel, their primary care physicians, rheumatologists, upper extremity or orthopedic specialists, imaging and radiology personnel.  Our patients are already overwhelmed with all of the paperwork that is required at each of these facilities (intake forms, health history, notice of privacy practices, notices of patient’s right and responsibilities, functional assessment forms).  And now we are being told that we, as occupational therapists, need to take height and weight for a Body Mass Index, ask about alcohol and tobacco use, ask about history of falls, and administer a depression screen and an elder abuse screen before we can even begin to address the reason that our patient was originally referred to our hand therapy clinic.  I anticipate that these screenings will be a time-consuming and frustrating process for the therapist as well as for the patient who just wants to focus on what they can do to make their upper extremity injury better.

I spent many hours over the weekend reviewing the PQRS measures and developing a checklist that will hopefully meet Medicare requirements while not being overwhelming for either the therapists or the patient.  However, I would love to hear how other clinics are addressing the issues.  Or how clients feel about these changes.  Any tips?  Advice?  Stories of how addressing these issues made a positive change (as I’m trying to keep an open mind)?  Any thoughts on how to best handle the counseling or referral process if any of the measures requires intervention?

It will be interesting to check back in a year, to see the impact of PQRS on our small clinic.  At best, I’m hoping to discover opportunities for growth and expansion.  At worst, we will just survive the additional paperwork.    In the meantime, I’m looking forward to hearing from you.

Best wishes for a happy and healthy year!


The Use of Compression Gloves for Hand Swelling

Compression gloves are often recommended for a swollen hand or finger.  The blend of nylon and lycra provides a comfortable, gentle squeeze that helps reduce swelling.  These gloves are thin and unlined so that they move with the hand and do not get in the way of hand use.  You can often purchase the gloves without tips (3/4 finger length) so that you have sensation and better purchase at the ends of the fingers for easier hand  use.  The seams of these gloves are deliberately placed on the outside of the glove to provide a smooth and even fit, to increase comfort, and to prevent pressure areas and friction.  The gloves also provide a low-level warmth that can be comforting to painful and stiff finger joints.


Preventing Frostbite in the Hands

The hands can be at risk for frostbite when temperatures drop below 20 degrees Fahrenheit. With the sub-zero temperatures many are experiencing this week across the nation, here are a few tips to help you prevent a cold-related hand injury.
1. Wear appropriate clothing for the weather. Wool or a wool synthetic is warmer than cotton. Mittens are more protective than gloves. Insulate with several thinner layers of clothing rather than only one or two thicker layers. Top with a waterproof outer layer. Carry extra pairs of gloves with you in case the ones you are wearing become wet.
2. Check to be sure that no area of skin is exposed (for example, where the glove and the arm sleeve meet).
3. Check the fingers for signs of frostbite on a regular basis if you need to be out in the weather for any length of time.
4. Avoid use of alcohol or cigarettes. Both increase susceptibility to developing frostbite. Certain medical conditions (for example, neuropathy, diabetes, peripheral vascular disease, Raynaud’s) and medications can also increase risk of developing frostbite. Take extra precautions if you have a condition that puts you at higher risk.
Be aware. Be safe.