The Wrist & Repetitive Strain Injuries

The wrist joins the hand to the forearm. It is able to move forward and back, side-to-side, and in circular movements. This variety of motion allows the hand to reach objects and function in a wide range of motion. In addition, a strong and stable wrist is important during grip activities.The wrist is a complex joint where the two long bones of the forearm meet the eight small carpal bones of the wrist. These carpal bones are essentially arranged in two rows of 4 bones. The eight small wrist bones then meet the five long finger bones in the palm of the hand. Most of the muscles that move the wrist, fingers and thumb are located in the forearm. The tendons (the cords that connect muscle to bone) that bend and straighten the wrist and the fingers must cross through the wrist joint on their way from the elbow towards the hand.Many of the repetitive strain injuries associated with computer work occur at the wrist. In fact, according to the National Occupation Research Agenda for Musculoskeletal Disorders, the most frequently reported upper-extremity musculoskeletal disorders affect the hand and wrist region.

Carpal Tunnel Syndrome is the most commonly diagnosed nerve injury in the arm. The nerves are the power cords for the arms, providing strength to the muscles and sensation to areas of skin. Carpal tunnel syndrome is the compression of the median nerve as the wrist as it passes from the neck to the fingers. Carpal Tunnel Syndrome can cause pain at the base of the hand and in the bulky muscles in the palm right below where the thumb meets the palm. Also, people often say they feel as if they have a tight band around their wrists. Numbness in the thumb, index and middle fingers is common. The pain may feel as if it is traveling up the arm and into the shoulder and neck

Pain where the thumb meets the wrist may be caused by a tendinitis of the muscles that pull the thumb back (as if you were hitchhiking). People who type tensely are prone to developing this tendinitis as they hold their thumbs over the keyboard with tension. Pain at the base of the thumb can also be caused by arthritis in the joint where the long palm bone meets one of the tiny wrist bones of the thumb.

Tendinitis of the wrist and finger flexors (the bending/closing muscles) and extensors (the straightning muscles) and benign ganglion cysts also occur fairly frequently at the wrist.

RSI Prevention

  • Maintain a neutral wrist position.
    • The wrist should be flat in relationship to the forearm; it should not be bent forward or back.
    • For each 15 degrees that the wrist is out of alignment, the pressure on the median nerve increases.
    • The middle finger should be in alignment with the forearm, not angled toward the thumb or the small finger.
    • Wrist supports can provide proper positioning during the night.
    • Do not fight against a wrist support. It is better to remove the brace and perform activities carefully than to wear a brace that prevents necessary movement.
    • Softer, neoprene braces without the rigidity provide support but also allow for some movement and may be a better choice is the task requires wrist movement.
    • Using a wrist brace can cause the body to compensate for loss of motion by moving the elbows differently. Monitor for a shift in pain symptoms in other body areas.
  • Ergonomics
    • Using a split keyboard can align the wrists into a more neutral position.
    • Try a negative tilt of the keyboard where the row of keys closest to you is slightly higher than the row farthest away.
    • The keyboard height should allow the wrists to be neutral while the shoulders are relaxed and the elbows are open slightly greater than 90 degrees.
    • Use the upper arm to manipulate the mouse. Do not activate the mouse by using side-to-side movements of the wrist.
    • The mouse should be located by the keyboard. Do not reach forward to activate the mouse positioned on a different level than the keyboard or positioned out of easy reach.
    • Keep the fingers and thumb relaxed on the keyboard. Use only the minimum necessary force to activate the keys. Do not float the fingers stiffly over the keyboard.
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A Good Week & Thoughts on Healthcare Trends

A Good Week & Thoughts on Healthcare Trends

The last several weeks have been really good weeks- those types of weeks where you just feel really good about your career choice; those types of weeks where you feel as if you are making a difference in people’s lives. The reason? We had several former clients stop by the clinic to say thanks and to let us know how they were doing. One brought us a bouquet of gorgeous Dahlias. He has one of the largest collections of Dahlias around. He continues to treat us with these beautiful flowers even 3 years after he graduated from hand therapy because of the positive impact we had on his life during a difficult time.

And this case is not unusual. Some common refrains that we hear from our clients are: you provide me with the knowledge I need to recover from my injury; I don’t feel as worried or frightened about the injury and my recovery because I now have that knowledge; and I wish I had known this information earlier.
Unfortunately, as healthcare changes, I see a trend towards fewer referrals, towards fewer people receiving the benefit of our experience. We are having to fight harder to receive authorization for fewer visits with less reimbursement. In spite of my good weeks, now I am the one feeling worried and frightened ….about the future of my profession as an occupational therapist and a certified hand therapist.
A few examples of this trend: (please note that these examples are based on situations with physicians who do not regularly refer to our clinic) Last week I worked with a client who returned to the clinic to be treated for a right carpal tunnel release about 6 months after being seen for her left. She felt she had progressed very well with the previous therapy, returned to work almost immediately post surgery, and was quite pleased with her end result. She assumed her physician would refer her once again for therapy for this recent surgery on her dominant hand. The physician did not. At her second follow-up visit with the physician, surprised that therapy was once again not mentioned, she requested it. Her physician reluctantly wrote a prescription “but for only a few visits”. She was glad to have these few and upon completion, she requested a few more feeling that she had just a bit more work to do with us. Based on early return to work with residual swelling, scar thickness, limited grip and pinch strength, and a moderate pain level with typing, our progress note to the doctor also reflected that a few more visits would be beneficial. However, her physician told her that she should be grateful for what she got as this particular physician only refers 1% of patients to therapy. 1%!
I think I recall coming across a statistic a while back that most hand surgeons refer about 10% of their caseload to therapy services. (I have not been able to find this source again. I would love to have this confirmed if anyone out there has information). So what is happening with the other 9% of the patients that are not being referred? Are they receiving sub-optimal results? Taking longer to recover? Staying out of work longer? Just getting by? Finding information on the Internet instead of through qualified personnel? Having multiple questions that go unanswered? Putting energy into worries that can be resolved with education?
I once had another physician ask one of my clients who had requested therapy, “Why? Do you need someone to hold your hand?” Is that how scar management, retrograde massage, joint mobilization, manual therapy, range of motion is viewed? As hand holding
And, if people are being seen by physicians who seem as callous as in these two examples, I don’t think that a session or two of our “hand holding” is out of order. Why does medicine need to be so cold and unsympathetic? And why do some physicians believe that it is more effective that way?
And for those physicians who believe in our services, even they are being impacted and discouraged by the hounding of insurance adjusters, multiple phone calls received, and the increased need to prove medical necessity (often to ridiculous degrees). It is becoming easier for even them to not take out the prescription pad.
Dr. Roy Meals referenced a study in his newsletter that he believed every hand therapist should be aware/wary of. This study “proved” that wrist fracture recovery was better without the “coddling” of physical or occupational therapists. Of course, the control group (those who did not attend therapy) were seen for frequent follow up visits with a physician who spent 10 minutes each appointment providing them with exercise instruction. Unfortunately, all of the physicians who refer to me do not have that luxury anymore. They count on us to provide eduction and home program instruction. But, if insurances can use this study to deny treatment, do you think they will make that distinction? I sure don’t.
So, what can we do to offset what seems to be an increasing disbelief and disrespect of our services? I personally don’t know what the answers are. Maybe insurance companies (who i believe to be the driving force behind this ennui) are just too big to fight. But in the meantime, I will carry-on at a grassroots level by trying to promote my profession, by returning those annoying calls to adjusters, by answering questions and providing education, by suggesting that my clients tell any and all about the value if services that they receive from us. I will support our local and national organizations who can fight at a political level. And I will hope for the best because I want to continue to have these good weeks.
Best, Marji

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Repetitive Strain Injury -A Computer User’s Guide

Years ago, I had the good fortune to attend a conference at which Dr. Emil Pascarelli spoke. Considered to be one of the world’s leading authorities on repetitive strain injuries, Dr. Pascarelli is as good a writer as he is a speaker. His book, Repetitive Strain Injury – A Computer User’s Guide, is highly recommended for anyone who works on a computer or at a desk. His first book, published in 1995, is an easy-to-read and concise summary of his approach to repetitive strain injuries (RSIs). It was one of the first written about RSIs, and it continues to be one of the best.

Dr. Pascarelli began his study of RSIs not with computer users but with musicians who experienced upper body pain after intense practices and stressful performances. His successful approach was to treat the musician comprehensively by improving a combination of playing technique, positioning, posture and general physical conditioning. Similar problems – improper typing style, poor computer and work ergonomics, an ill-fitting workstation and equipment, a lack of postural awareness, and poor physical conditioning – were observed and addressed when computer users began seeking treatment at his clinic.

Deborah Quilter co-authored Repetitive Strain Injury – The Computer User’s Guide. Ms. Quilter is a journalist and an RSI sufferer who developed painful symptoms so severely that she was in danger of not being able to perform her job. After seeking treatment from Dr. Pascarelli and beginning the slow journey to recovery, Pascarelli and Quilter joined forces to write this guide as a resource to help those already dealing with RSI and to prevent others from developing it.

Between Dr. Pascarelli and Ms. Quilter, thousands of people suffering from RSIs have been observed, treated, and interviewed to provide the common-sense recovery and prevention information outlined in their Seven-Point Program. Their seven-points include the necessity to find a physician who can diagnose and treat the injury appropriately, to develop appropriate pain management techniques, to perform preventive stretching and strengthening exercises, to develop postural awareness, to acquire proper workstation positioning and equipment, to pace activity, and to have patience during the recovery of these slow-healing injuries.

The authors take the reader through all the steps of the RSI process beginning with a risk assessment, symptoms checklist, and discussion of common examination and treatment procedures. They then outline treatment options, give advice on performing daily activities in less physically demanding ways, provide vision care and exercise guidelines, and discuss the emotional aspects of living with an RSI. Lastly, Dr. Pascarelli and Ms. Quilter outline prevention techniques through ergonomics, workstation set-up, and typing retraining.

Although the authors provide brief descriptions of a variety of injuries, this is not a medical text. Rather, it is a comprehensive, practical approach to a complex problem written in an easy format with quotes and drawings that enhance the information provided. Repetitive Strain Injuries – The Computer User’s Guide is a necessity for anyone who is trying to avoid injury or who is looking for more than a temporary, quick fix of medication or cortisone to alleviate their computer-related pain. It is a must-read for those with chronic pain who are willing to take charge of their own recovery rather than relying on the unreliable and possible ineffective medical and insurance systems for answers.

Repetitive Strain Injuries – A Computer User’s Guide is available at Amazon.com.

Top 10 Ways to Avoid Computer-Related Pain

The following recommendations make my top ten list for avoiding carpal tunnel syndrome, tendinitis and other computer-related strains and pains.

    1. Don’t squeeze the mouse too hard. Keep a loose grip.
    2. Don’t swivel the wrist while using the mouse. Move through the shoulder and elbow.
    3. Keep the wrists neutral. And try going vertical (with a vertical mouse).
    4. Don’t reach up or outward for the mouse. Keep it on the same level as the keyboard and keep it in close.
    5. Don’t rest your wrists on the wrist rest. This places pressure directly over the carpal tunnel and isolates finger movement causing too much strain on small muscles.
    6. Type lightly. Keep the fingers relaxed. Float over the keyboard.
    7. Open the elbows slightly greater than 90 degrees. Use an under-the-desk keyboard tray to position the keyboard at the correct height. Or, if you need to raise the chair seat, make sure your feet are properly supported.
    8. Avoid the rounded shoulder and forward head posture. Sit properly with the ears, shoulders and elbows in vertical alignment.
    9. Place the monitor at eye level so you don’t strain the neck and shoulder muscles by looking down at the screen.
    10. Don’t use bifocals. Peering under the lens can cause awkward head positioning and promote neck strain. Obtain special glasses for use only on the computer that are prescribed for the distance between your eyes and the monitor.

The Fingers & Repetitive Strain Injuries

Anatomy

The fingers have no actual muscles in them. Rather, the movement of bending the fingers is caused by the muscles in the forearm contracting and pulling on the tendon (the long, rope-like structure that connects muscle to bone) that attach to the fingers. These muscles start at the inside edge of the elbow.

The muscles that straighten the large knuckles of the hand are also forearm muscles that start at the outside edge of the elbow.

There are small muscles within the hand (palm area) that straighten the finger tips and provide fine motor control.

Trigger Finger

The tendons that bend the fingers run through a pulley system within the finger itself. The pulley system is necessary to hold the tendon close to the bones and prevent bowstringing of the tendon. This system maximizes the efficiency, motion, and strength of grip.

Unfortunately, one of the most common repetitive hand injuries occurs within this pulley system. Over the front of the palm, at about the level of where the large knuckles bend, the tendon passes underneath a ligament bridge. If the tendon becomes swollen and inflamed, it does not pass smoothly underneath this ligament. The resulting friction may cause the tendon to “hitch”, get caught, snap, and feel as if it is not working effortlessly. The finger may also “lock” when the swollen tendon pops through the tightness but is unable to pass back underneath. If this happens often enough, or if the finger is painful or the swelling tight enough, the finger can actually begin to contract at the joint and it may become physically stiff. The palm area at the site of this inflammation can also become quite tender and painful. This triggering can occur in any of the fingers and the thumb.

Arthritis

Other than trigger finger, the most commonly occurring, non-traumatic injuries that occur in the hand tend to be arthritic in nature. Osteoarthritis is caused by wear and tear on the joints. This type of arthritis is not necessarily caused by actual age, but by the mileage (physical stressors) put on the hands over the years. That said, there does seem to be a genetic predisposition towards developing osteoarthritis. Although not directly a repetitive strain injury, arthritic joints can become inflamed and painful with work activity.

Heberden’s nodules are calcifications caused by arthritis at the top joint of the fingers. Bouchard’s nodules are calcifications caused by arthritis at the middle joints of the fingers. These nodules can enlarge the joints and make them painful and unstable. Once the fingers have had joint changes due to the arthritic process, the joint cannot return to its normal state.

With arthritis, the goal is to prevent joint changes by using the hands more gently or in a supportive way. Joint protection techniques, energy conservation techniques, and the use of adaptive equipment are all prevention methods that are associated with the attempt at preventing arthritic joint changes.

Below are some ergonomic techniques that will help prevent the overuse activities that can cause inflammation or trigger finger and the physical stressors that can promote osteoarthritis.

Ergonomics

Avoid sustained gripping or pinching activity. 

  • Use a larger grip if possible;  for example, use pens with a larger barrel such as the Dr. Grip; or use kitchen utensils designed with the Good Grip handles – these are comfortable to use and take the stress off the hands.
  • Do not hold/squeeze the mouse with any force.
  • Rather than holding a book, place it on a surface (such as a bean-bag lap tray) and use the palms to hold it open; or use a weighted book mark to hold it open for you.
  • Use specially designed ergonomic tools with larger and softer grips; check industry catalogs for equipment specific to your type of occupation/work.
  • Use electric tools and gadgets (e.g., can opener) rather than manual tools

Avoid repetitive gripping (opening and closing the hand).

  • Use the lightest touch possible to activate the keyboard.
  • Use rotary scissors or self-opening scissors.
  • Open bottles/jars using the flat palm of the hand rather than a large, finger grip hold.

Pacing Activity

  • If unable to avoid the above activities, take frequent micro-breaks.
  • If possible, rotate activities throughout the day so that you are not performing any one type of hand-intensive activity for any length of time.
  • Do not go home after performing heavy or repetitive work and immediately perform leisure or housework activity that uses similar motions.
  • Use a cold pack for 10 minutes after any activity that causes pain.

Joint Protection and Energy Conservation

The general principles of Joint Protection and Energy Conservation are to avoid a sustained position, use leverage versus a grip when possible, use the largest joint possible for the activity, respect pain, and balance work and rest. Visit Hand Health Resources for detailed information on tendon and joint protection principles.

Exercises

Stretch often.

  • A great stretch for the hand and forearm is to put your arm out in front of you with the palm down then pull the wrist back as if you are saying “stop”. Gently increase the stretch by pulling the wrist and fingers back with the other hand. Hold for 30 seconds.
  • You can also open your hand and spread your fingers open as widely as you can.
  • Gently pull each finger back using the other hand.
  • A great stretch for the smaller muscles within the palm area of the hand – make a hook fist (try to touch the fingers to the very top edge of the palm as if you are holding a briefcase or a grocery bag; the large knuckle should be straight and the two end knuckles of the fingers are hooked into a fist). Maintaining the hook, gently push the large knuckle back into more extension using the other hand.
  • If having hand/finger pain, do not exercise the hand by using grippers or squeezing a ball. Rather, use a rubber band placed at the tip of the fingers for light resistance as you open the hand. This works the opposite muscle groups and creates balance, rather than stressing muscles that are already over-worked.

Neutral Position

  • There is a natural, soft curve to the fingers.
  • Many people are tense sleepers who tend to make a tight fist at night. Try to sleep with the fingers mostly straight. If needed, use a splint such as the Pil-O-Splint to keep the fingers from fisting in the night.

Laptop Ergonomics

Laptop computers and portable technology have changed the way we do business. With portable equipment, we are now able to work away from our primary office in a temporary or more comfortable location. We now have the luxury of working in a secondary or off-site office, while traveling, from the comfort of our home, and while lounging on the couch. However, in spite of their many benefits, portable computers, by their nature, increase the risk of developing repetitive strain injuries.

  • The keyboard and screen are attached in one unit. Because they are unable to be adjusted independently, an ergonomic compromise is created on positioning and comfort of either the neck or the arm.
  • Laptops are often used in cramped spaces compromising posture.
  • Laptop keys are smaller than traditional, desk-top keyboards causing the potential for increased hand and finger strain.
  • Laptop screens are typically smaller than standard causing potential eye strain.
  • It is harder to adjust the laptop screen to reduce glare.
  • Portable equipment is heavy to carry.

These shortfalls create the risk for pain, aching and muscular fatigue in the neck, shoulders, back, elbows, wrists and hands. They also create the potential for eye strain, headaches, numbness and tingling in the arms.

Putting these simple ergonomic adjustments into practice can help you reduce the risk of developing injuries while working on your laptop.

  • Stretch often.
  • Be aware of posture.
  • Take frequent breaks, every 20-30 minutes if possible.
  • Change your position often.
  • Switch the laptop position from the lap to the table every 30 minutes.
    • Putting the laptop in your lap will relax your shoulders.
    • Putting it on the table will relax the neck and reduce eyestrain.
  • Limit the peripherals you carry to the bare essentials to reduce the weight you carry.
  • Use a carrier with padded straps and frequently change the shoulder that the bag is carried on; or use a backpack with both straps over the shoulders to distribute the weight; better still, use a carrier with wheels.
  • Follow standard ergonomic positioning for a keyboard as closely as possible.
    • Keep the wrists neutral.
    • Keep the elbows open to 90 degrees or slightly greater.
    • The ears, shoulders and elbows should be in vertical alignment.
    • The shoulders should be relaxed. Do not round shoulders forward or hunch them up towards the ears.
    • The head and neck should be relaxed. Do not let head drop forward out of alignment with shoulders.
  • Use proper finger positioning, typing & mousing techniques.
    • Use two hands for 2-key functions.
    • Use the stronger fingers (modified hunt and peck) rather than stretching the fingers to reach for keys.
    • Keep the fingers relaxed.
    • Use a light touch while typing.
    • Movements should come from the larger shoulder muscles. Do not isolate the smaller wrist and hand muscles while typing by planting the wrists down.
  • Prevent eye-strain and headaches.
      • Frequently look away from the screen and look at an object far in the distance. Follow the 30-30-30 rule.
        • rest the eyes for 30 seconds
        • by looking 30 feet away
        • for every 30 minutes of typing
    • Rub your hands briskly together until warmth is created and then place your warm palms over closed eyes. Hold the position for 20 seconds.
    • Frequently clean the screen using the appropriate antistatic cleaners.
    • Adjust font for color, contrast and size so that reading the screen is comfortable.

If you use the laptop as your primary computer, it is especially important to be aware of your positioning.

  • When you are in your office or primary work environment, elevate the laptop using monitor risers so that the screen in an optimal position and you do not need to bend your neck when looking at the screen; then, connect a separate keyboard and mouse at elbow level to position the arms appropriately.
  • When sitting in a chair without elbow supports or a couch, use pillows to support the arms whenever possible. Keep the same general ergonomic positioning guidelines in mind even if you are in a relaxed work environment.

The following exercises will help you stay flexible and keep you pain-free.

  • Stretch the thumb by gently pulling it back. Hold for 20 seconds.
  • Stretch the palm up. Hold for 20 seconds.
  • Perform basic forearm stretches.
    • Place your hand out in front of you as if you are saying “stop” and pull the fingers gently back with the other hand. Hold for 20 seconds.
    • Now let gravity drop the wrist down and gently increase the stretch by pulling with the other hand. Hold for 20 seconds.
  • Stretch the triceps and biceps.
  • Perform shoulder and neck stretches.
  • Stretch the back.
    • Gently interlace the fingers behind the neck and arch your upper back as if you are trying to look up at the ceiling (be careful not to pull the head forward). Hold for 20 seconds.
    • Place your hands on your hips and arch the lower back as if you are trying to look up at the ceiling. Hold for 20 seconds.
  • Perform 15-20 minutes of daily cardio activity to improve circulation and oxygen flow to the arms for improved conditioning and better healing.
  • Perform core strengthening exercises to improve general postural stability.

Typing Style – Repetitive Injuries are NOT just about the Keyboard

The goal of ergonomics is to reduce the force, repetitiveness or awkwardness of activities so that the body performs tasks most efficiently and with the least amount of stress. Many excellent resources are available that describe ergonomic modifications for the office environment. Because of this information, most people now have some general knowledge of the healthiest location for the keyboard and monitor. Less commonly known is that typing style can be the cause of injuries.

TYPING STYLES

In their book Repetitive Strain Injury: A Computer User’s Guide, Dr. Emil Pascarelli and Deborah Quilter describe a variety of typing techniques that can lead to painful symptoms and repetitive injuries. Even the best and most expensive ergonomic keyboard will not eliminate pain caused by the following typing methods.

Resters – Resters lean the base of the hand upon the desk or the wrist rest. This can be harmful for the following reasons: 1) It places point pressure against the carpal tunnel; 2) It isolates the small muscles of the hands and forces them to do the work of the larger shoulder and elbow muscles; and 3) It can promote wrist postures that are not neutral.

Leaners – Leaners type by placing their elbows on the desk or chair arms. This puts pressure on the ulnar nerve, the superficial nerve at the elbow.

Loungers – loungers slump in their chairs leading to compression of the spine and low back pain. Lounging also promotes forward head and rounded shoulder posture.

Clackers or Pounders – Pounders hit the keys with excessive force potentially leading to pain and tingling in the finger tips and finger joints.

Pressers – Pressers hold down keys (for example, while scrolling) with excessive force placing pressure on the small joints in the fingers.

Pointers – Pointers are hunt-and-peckers who hold their arms poised in midair. Pointers are at risk from awkward positioning if they hold their fingers stiffly rather than in a relaxed position or if the keyboard is not positioned correctly.

Thumb or Pinkie Extenders – Extenders hold one finger stiffly out while the others perform the work. This separation causes excessive strain on the tendons of the fingers.

Grippers – Grippers hold tightly to the mouse or use too much force when clicking.

TYPING-STYLE ERGONOMICS

The following typing tips describe work-style modifications that will help prevent injuries and maximize the benefit of that ergonomic keyboard.

  • When typing, keep the fingers relaxed and slightly curled as if they are resting over a large ball.
  • Tap lightly with the finger tips rather than with the pulp of the finger.
  • Keep fingernails short – longer nails require that the fingers be tensely extended so that the key can be tapped with the pulp of the finger.
  • Keep the thumb relaxed – not held stiffly over the space bar.
  • Use the lightest touch possible on the keys.
  • Don’t stretch the fingers to reach keys that are far from the home row. Move fingers closer to the key by moving the whole arm.
  • Don’t stretch the fingers wide to activate a two-key command with one hand. Use one finger from each hand to activate these commands.
  • Maintain a neutral wrist position.
  • The mouse should be held loosely. Control of the mouse should come from the larger muscles of the elbow and shoulder, not from wrist motion.
  • Don’t rest the wrist on the table or wrist rest. Use the wrist rest as a guide that the wrist slides over.
  • Don’t lean on the elbow when typing, talking, contemplating, or holding the phone.
  • Pad any sharp edges that the forearm rests against.
  • The keyboard and mouse should be positioned so that the arms are at the sides (do not reach forward or out to the sides to activate either), shoulders relaxed, elbows opened up slightly more than 90 degrees.

Repetitive Strain Injury: A Computer User’s Guide offers more tips and exercises to help correct typing styles. Find it at Amazon.com.