Top 10 Ergonomic Picks

Here are my top 10 picks for ergonomic health that can help reduce the risk of carpal tunnel and other repetitive injury pain when working at the keyboard.

1. An Ergonomic Keyboard – Positioned with a wedge-shaped inverted “v” (also described as a “gable”), the split-keyboard places the wrists in a more neutral position than smaller, standard keyboards.

2. An Ergonomic Mouse – The Evoluent Vertical Mouse and the 3M Ergonomic Mouse are two styles of mice that place the forearm in the “handshake position” easing stress and tension on the muscles, tendons and nerves of the arm.

3. An Adjustable Under-the-Desk Keyboard Tray – Allows you to easily position your keyboard at the appropriate height. A must for any workstation, at home or in the office, that has multiple users. Many trays now also adjust for keyboard tilt allowing improvement for wrist angulation.

4. An Adjustable Monitor – Allows you to easily position the monitor at the appropriate height easing neck and shoulder pain. Once again, a must for any workstation that has multiple users.

5. Computer Glasses – Anyone who wears glasses, especially bifocals, is at high risk for neck and shoulder strain while working on the computer. Purchase a new pair of glasses that is prescribed specifically for computer use.

6. A Stretch-Break Program – You can not over-stretch while working (as long as you respect pain when performing the stretches). A program such as StretchSmart can cue you to take stretch breaks. You can customize the frequency and duration of the stretching sessions. You can also set the program to provide stretches for your specific high risk pain areas.


7. A Copy Holder
Eases neck strain caused by looking repetitively from the monitor to the desk while working from copy. If working with thicker stacks of copy, an on-the-desk model that fits in front of the monitor works well. Single sheets of copy can be placed directly to the right or left of the monitor.8. An Ergonomic Pen

The majority of people who I see for ergonomic assessments have a tendency to hold their pens too tightly causing thumb and hand pain when writing. Hold the pen lightly, using a roller-ball or felt-tip pen so less force is needed.9. A Good Chair

Your office chair should be adjustable for height, seat-depth and seat-tilt. It should have adjustable arm rests and good lumbar support. For petite women, a full-length lumbar back support may be helpful to improve the fit of the chair.10. A Good, Durable Cold Pack

We all have aches and pains now and again. The key is to keep an injury from progressing and settling in. Have a good cold pack readily available for use at the first sign of inflammation or pain. The ElastoGel Cold Packs are a clinical therapeutic favorite. They are durable, will not leak, and conform comfortable around bony areas. A cold “wrap” comes with Velcro straps attached that allow you to strap on the pack when you are on the go.

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Reflections On Being An Angel

Reflections On Being An Angel

Last week, a patient told me I was his angel.

Being caught up in the normal busyness of everyday life, I haven’t had a chance to reflect on the meaning of his statement until now. Did I do anything special or miraculous to deserve the title? Nope. I just did my job – hopefully in a caring, compassionate and respectful manner. So why was this glorified designation bestowed upon me?

This intelligent, energetic man had his life unexpectedly turned upside down after waking one morning with red streaks heading up his arm. During a home project several days earlier, he had jabbed and cut his thumb with a screwdriver. Having been a pharmacist, this gentleman knew all the right things to do. But that didn’t stop the infection from coming. He’d just been to surgery to have the wound cleaned and then his surgeon referred him to me.

When he arrived, my patient told me that he was anxious; that his wound didn’t look good; he didn’t like the color; it was healing too slowly; it didn’t feel right. During our first session, I cleaned and redressed this gentleman’s wound, I reassured him that the wound looked healthy and not infected, I guided him in exercises to prevent stiffness, and I learned that he had a granddaughter graduating from 6th grade that afternoon.

When he returned for his second visit, this patient of mine brought his wife. The wife was excited to tell me that her husband had come home a different man after that first visit. Much of the worry about his injury was gone.

At his third visit, the gentleman was pleased to tell me that he felt 80% better than at his first visit. He also told me that he had sung my praises during a visit to his internist that morning. Although he was exuberant in his thanks, did I believe that I had done do anything angelic yet? Still, no. Just putting in a good day’s work.

All I did, in addition to providing wound care and range of motion exercises, was listen, give reassurance and hold out the hope that there would be a full recovery. Yet, I’m told more and more often by my patients that health care professionals are too busy to answer questions or to provide comfort. This isn’t surprising as reimbursement for medical services is being cut and caseloads are increasing.

Another common phrase we hear in the clinic – “Why didn’t anyone tell me these things before?” It is often left to the therapist to provide injury information and recovery education. With our health care system, physicians are just too busy. It is a good thing that we, as therapists, still have the time to develop a therapeutic relationship and be a safety net….as long as we are getting referrals. But where are the angels for those who aren’t referred due to lack of insurance or who have a high deductible; who have busy schedules and are unable to attend; or who have doctors who decide to wait, sometimes for a month or two or even longer, until a problem is large enough to warrant referral?

Our profession recently celebrated Hand Therapy Week. It was a good time to reflect on the qualities that we have that enable us to treat upper extremity injuries with skill. But we must never forget that it is the personal relationships that we develop with our clients that give us the ability to change lives.

Would my patient’s wounds have healed if he had never set foot in my clinic? Absolutely. But, it would have been a longer, more stressful, lonely journey for him. And I guarantee that he would not have enjoyed his granddaughter’s graduation as much as he did if, during the ceremony, he was as worried about his hand as he had been when he first arrived at our clinic.

So, I will try to remember, in spite of all the administrative stressors, why I became an occupational therapist in the first place. I will appreciate the hugs my patient gives me after every treatment session. And I will accept this man’s role as his angel with honor.

Best wishes, Marji

Smartphone Ergonomics

Since their inception, the push has been to make computers smaller, smarter and more portable. Functions that once took banks of computer hardware are now performed on electronic gadgets that fit in the palm of our hand.1973 heralded the birth of hand held computers with the first programmable calculator. Within 2 years, a primitive and portable computer organizer was developed with a calculator, alarm clock and scheduling feature. The first “palmtop” with DOS was developed in the mid 1980s. John Sculley of Apple Computer officially coined the term PDA (personal digital assistant) in 1992 when he introduced the Apple Newton. The mass market appeal of these small devices was realized with the introduction of the Palm Pilot in 1996. About the same time, the first “smartphone” (a combination of cellular phone and PDA) was developed. The popular BlackBerry was introduced in 1999. Currently, 2.14 billion people worldwide subscribe to mobile phone service (en.wikipedia.org/wiki/mobile_phone).

In a piece of electronic equipment the size of the palm of our hand, we now have the ability to make phone calls, take pictures and videos, access calendars and address books, check email, surf the web, perform office tasks and develop business documents with mobile versions of word processors and spreadsheets, locate areas of interest and avoid traffic jams with GPS, play games, and entertain ourselves with music and video downloads.

The following ergonomic and safety tips will keep you healthy and pain-free when using your handheld device.

“BlackBerry Thumb”

Text-messaging and miniature or keyboard functions can take their toll on the thumbs. “BlackBerry Thumb” is a commonly used term to describe a painful and debilitating tendonitis of the thumb tendons caused by repetitive use.

    • Limit your typing time to no more than 10-15 minute sessions.
  • Stretch often.
    • Turn your palms up.
    • Open the thumbs wide as if you are hitch-hiking.
    • Using your other hand, gently push the thumb back until you feel a nice stretch.
  • Use a portable keyboard attachment when possible.
  • If using a stylus, use one with a larger grip handle.
  • Support your arms on pillows while typing.
  • Hold a pencil and use the eraser to push the keys to give your thumbs a break.
  • If your thumbs feel sore, use cold packs after typing. Take a break from using your thumb keyboard. Seek medical attention if the pain does not go away.

The Elbow & Repetitive Strain Injuries

Unlike the shoulder, the elbow joint has a tremendous amount of bony stability. The lower end of the long bone of the upper arm (the humerus) meets the two long forearm bones (the radius and the ulna) at the elbow. The majority of the muscles that bend the wrist and the fingers attach to the inner portion of the elbow. The majority of the muscles that straighten the wrist and the fingers attach to the outer portion of the elbow.

The neutral position of the elbow, with the arm relaxed at the side of the body, is with the thumb facing forward and the palm facing toward the body. With the elbow bent, this neutral position is the “handshake” position.
Factors that Contribute to Elbow Pain

  • Repetitive wrist movement, especially with the forearm fully rotated palm-up or palm-down, repetitive rotation of the forearm, and repetitive elbow bending and straightening can all contribute to inflammation of the tendons as they insert into the elbow.
  • Bony and ligamentous grooves and tunnels near the elbow through which the three main nerves that provide power and sensation to the hand pass. The shearing motion or compression of the tendon and nerves as they pass through these tight areas can contribute to repetitive strain injuries.
  • The degree of the elbow carrying angle (the angle of deviation of the forearm bones in relationship to the upper arm bone when the arm is held at the side with the palm facing forward).
  • Maneuvering the arms around a larger upper body when placing the hands on the keyboard is also a factor.

Cubital Tunnel Syndrome

When you hit your “funny bone” you are actually hitting the ulnar nerve as it passes through a bony groove at the inside of the elbow. The nerve is particularly vulnerable as it passes through this superficial groove. Bending the elbow stretches the nerve through this groove tautly. Holding the elbow bent for prolonged periods, such as when holding a phone to the ear or sleeping with the elbows bent, can cause this nerve to become irritated. If you experience aching along the small finger (ulnar) aspect of the forearm and hand, or if you have tingling or numbness in the ring and small finger, it is especially important to avoid positioning the elbow in a bent position, either with activity or at night. Avoid repetitive elbow bending and straightening. Contact a medical professional for treatment.
Tennis Elbow (Lateral Epicondylitis)

Tennis elbow initially begins as an inflammation where the muscles attach to the outside edge of the elbow. Activities that contribute to this inflammation include repetitively pulling back (extending) the wrist and the fingers; repetitively rotating the forearm palm-up and palm-down, especially when holding an object in the hand; and lifting objects with the forearm rotated in the palm-down (pronated) position. Carrying a suitcase, briefcase or laptop backpack are activities that can cause tennis elbow.
Golfer’s Elbow (Medial Epicondylitis)

Golfer’s elbow is similar to tennis elbow, except that it begins as an inflammation where the muscles attach to the inside edge of the elbow. Activities that contribute to this inflammation include repetitively bending the wrist and closing the fingers; performing fine motor activities with the wrist bent, and repetitively rotating the forearm.

The farther away from the body that you perform activity, the more tension that is placed on the tendons where they insert into the elbow.

RSI and Prevention

Positioning

      • Avoid sleeping with the elbow bent more than 90 degrees to reduce the amount of stress on the nerve.
      • Don’t sleep with the hands placed behind the head.
      • Avoid sleeping on your stomach.
      • Use soft pillows under the arms.
      • Wear a sleeve with a pad that protects the elbow or wrap an ace bandage around a small, soft pad.

Computer Use

    • Position the keyboard so that the elbows are open more than 90 degrees.
    • Pad any sharply angled surfaces that the arms rest upon. Or place a folded towel under the arms as a cushion.
    • Don’t lean on the elbows.
    • Avoid repetitive elbow bending and straightening, excessive wrist movement or repetitive forearm rotation.
    • Use a split keyboard, especially if you find that you need to deviate the wrists out of the
      neutral position (middle finger in line with the forearm bones) when placing the fingers on the keyboard. This is particularly important if you have a large elbow carrying angle or a larger upper body.
    • Move the mouse from the shoulder, not the wrist.
    • Take frequent micro-breaks.
    • Stretch often.

Trigger Finger – Repetitive Strain Finger Pain

Mouse and keyboard use can cause finger pain. One common cause of finger pain is called trigger finger. Trigger finger is a swelling of the tendon or tendon sheath in the palm of the hand of the tendons that bend the fingers. This swelling prevents the tendon from gliding smoothly through the sheath and the “pulley” (ligament) which holds the tendon to the bone. Trigger finger occurs most frequently in the middle finger and the ring finger, but it can occur in any finger or the thumb.SYMPTOMS

  • A locking, snapping, popping or catching sensation in the finger while making a fist.
  • This “triggering” of the finger can be quite painful at times.
  • The finger may “lock” into a bent position.
  • There will most likely be pain or tenderness in the palm of the hand over the site of the pulley which holds the tendon close to the bone.
  • There may be joint stiffness and pain in the affected finger.

OCCUPATIONAL CAUSES

  • Repetitively gripping or bending and straightening the fingers (e.g. – mouse clicking)
  • Sustained gripping (e.g. – squeezing the mouse forcefully or holding a pen in a “death grip”)
  • Using tools that have handles with sharp or hard edges

ERGONOMICS

  • Avoid repetitive grasping and releasing of objects. Modify the activity if you are unable to avoid it. Look for ergonomic mice or larger barreled pens. Change your typing style so that your fingers are relaxed on the keyboard and mouse.
  • Avoid sustained grasp.
  • Keep the fingers relaxed over the keyboard. Do not plant your wrist down on the wrist rest while typing as this causes excessive and stressful finger movements to reach all the keys. Rather, the wrist should glide over the wrist rest, allowing the fingers to be positioned over the keys in a relaxed manner.
  • Purchase tools with padded, comfortable handles.
  • Handles should have some texture for easier holding. Slippery surfaces require more forceful grasping.
  • Minimize repetition. Periodically rest the hands during repetitive or stressful activity. Stretch frequently during repetitive activity.
  • Slow down!
  • Use the lightest grip possible (on tools, pens, the mouse, the steering wheel, etc.) that still allows you to maintain good control.
  • Use the least amount of force necessary during the activity.
  • Use the appropriate tool for the job.
  • Use ergonomically designed tools if available (modified or padded handles, larger grips with good traction, handles with modified designs).
  • Make sure that tools are in good condition and that cutting edges are sharp (reduces the force needed to use the tool).
  • Alternate work activities so the hands are not performing any one task repetitively for any length of time.

And It Hurts…Here…Because? Ergonomic Recommendations

The location of where you are experiencing pain while working at a desk or on a computer can often give clues as to what needs to be adjusted during an ergonomic intervention.  Here is a quick guide of worksite and work-method recommendations that may help when you are feeling pain in a specific area.

Finger Pain – May indicate arthritic joints, a trigger finger, or strain from overuse.  Avoid squeezing the mouse too hard or pounding the keyboard.  Keep a light touch when typing.  Hold your pen lightly when writing.

Thumb Pain– May indicate a trigger thumb or DeQuervain’s Tenosynovitis.  Often occurs from either squeezing the mouse too hard or from tensing the thumb (as if hitch-hiking) over the keyboard keys.  Keep the thumbs relaxed using only the minimal amount of force needed to control the mouse.  When typing, keep the thumbs relaxed and just hovering over the keyboard.  Don’t pound the space bar.  Also, when writing, use a larger-barreled pen and don’t squeeze the pen too tightly.  Keep the thumb tip relaxed and only slightly bent – it is common for people write with their thumb tips bent at an extreme angle.

Wrist Pain or Pain at the Base of the Hand/Thumb– May indicate a tendinitis where the wrist muscles attach (flexor or extensor tendinitis), DeQuervain’s Tenosynovitis, or Carpal Tunnel Syndrome.  These are often caused by swiveling the mouse in or by poor wrist positioning.  Keep the wrist neutral (flat – not bent forward or back or angled side-to-side; the middle finger should be in a parallel line with the forearm).  Initiate small movements to control the mouse from the elbow and shoulder.   Don’t squeeze the mouse too tightly – use only the minimal amount of force necessary to control it.  Check your keyboard size and fit.  Pain over the small finger side of the wrist is often caused by the outward angulation of the wrist required to rest your hand on the home keys.  Using an ergonomic split keyboard is a quick-and-easy way to provide neutral wrist positioning.

Elbow Pain – May indicate an inflammation where the forearm muscles attach into the upper arm bone at the elbow – Medial or Lateral Epicondylitis.  Can also be caused by several nerve compression syndromes that occur near the elbow – Cubital Tunnel Syndrome, Radial Tunnel Syndrome.  Check out the positioning of the keyboard height and mouse location.  When working at a computer, your ear, shoulder and elbow should be stacked in a vertical alignment.  If your elbow is not relaxed at your side, you may need to change positioning by lowering the keyboard surface or getting in closer to your desk.  The elbow should not be bent at more than a 90 degree angle while using the computer.  A mouse that positions the arm in a more neutral “hand-shake” position may also be helpful.  Don’t swivel the mouse from the wrist.  Also, keep the hand relaxed on the mouse and use only the smallest amount of force necessary to activate the mouse click.  Don’t hold the index finger stiffly over the mouse (as if pointing) and don’t pound the mouse buttons, especially with a straight finger.  Rather, keep the index finger slightly bent and lightly touching the mouse.

Shoulder Pain – Often caused by reaching forward for long periods of time for the keyboard or mouse.  When working at a computer, your ear, shoulder and elbow should be stacked in a vertical alignment.  If your elbow is not relaxed at your side, you may be reaching forward causing strain on the arm muscles.  It takes work to hold the arm in this position for long periods of time even if the work itself is not too forceful.  To keep the upper arm muscles more relaxed, you may need to lower the keyboard surface or get in closer to your desk.  Check your chair.  Are you sitting back in the char?  Does it provide proper lumbar support and seat depth?  Look at the arm rest height.  You may need to lower the arm rests in order to keep the shoulders relaxed.

Neck Pain, Eye-Strain & Headaches – Often caused by poor positioning of the monitor.  Position the monitor directly in front of the keyboard so you are not twisting the body while using the computer.  Check out the height and distance of the monitor.  It may need to be adjusted so that you can clearly see the monitor print without tipping the head forward or back.  Avoid using bifocals while on the computer.  If you work extensively from copy, keep the copy in front of the monitor or directly to each side.  Use a tray that holds the copy close to monitor height to avoid repetitively looking up-and-down from the copy to the monitor.  Use a phone headset to avoid cradling the phone between the shoulder and the ear if you need to type and talk at the same time.

The Shoulder & Repetitive Strain Injuries

Anatomy

The shoulder is a unique joint in the body. It has a great deal of mobility in order to allow us to reach and perform activities away from our body. The cost of this mobility is a lack of stability. Most of the stabilizing forces at the shoulder are muscular and ligamentous rather than bony. These soft tissues that provide the shoulder motion and stability can be at risk for repetitive strain injuries.

The shoulder is composed of three bones: the clavicle (collar bone), the scapula (shoulder blade), and the humerus (long bone of the upper arm). The rotator cuff surrounds the shoulder and provides muscular stability for the humeral head. The shoulder blade controls shoulder motion. Nine of the fifteen muscles that attach to the scapula provide this motion.

RSI

With computer, desk, assembly or other types of hand intensive work, the neck and shoulders round forward and the upper arm tends to rotate inward. The chest muscles become tight. The muscles of the back weaken and stretch. The upper trapezius (the big, bulky muscles that make up the top of the shoulder) try to compensate by working harder than they should. Muscle knots and tension develop. The arms feel tired and weak. Eventually, this muscular imbalance can cause a tendonitis in the rotator cuff (supraspinatus) or in the biceps where it attaches to the humerus. Or the fluid cushion (bursa) between the rotator cuff and the shoulder bones can become inflamed (bursitis).

Poor posture can be the primary factor in developing shoulder pain. Other activities that tend to cause problems are prolonged or repetitive overhead reaching (such as when lifting binders or books down from shelves above the computer) or holding the arms elevated while typing, using the mouse, or performing other hand work. Tichauer (1978, The Biomechanical Basis of Ergonomics) discovered that a chair height that was 3 inches too low for a worker caused excessive shoulder movements and reduced productivity by as much as 50%.

RSI Prevention for Shoulder Pain

  • Neutral and Relaxed Shoulder Positioning
    • Postural awareness is of major importance in injury prevention.
    • The shoulders (upper trapezius muscle) should be relaxed while working.
    • Arms should be positioned at your side with the ears, shoulders and elbows in line.
    • Avoid rounding the shoulders or hunching forward
    • Maintain a neutral neck posture.
  • Ergonomics
    • Chair height should allow you to reach the work surface/keyboard/mouse with the elbows opened slightly greater than 90 degrees and the shoulders relaxed, not elevated.
    • Use of arm supports has been debated in the therapeutic community. The shoulders should be allowed to move freely to position the hands so that excessive movement is not required at the more vulnerable elbows, wrists and fingers. However, unsupported use of the arms is a contributing factor in shoulder pain.
    • If using arm rests, they should be positioned at a height that allows the shoulders to be relaxed. Do not plant the forearms down on the rests while typing. Allow the forearms to glide over the rests unless taking a break from hand activity.
    • Articulating Arm Rests are a good option for providing support with movement.
    • Position your activity and supplies so that repetitive or sustained lifting or reaching is avoided.
    • If you do need to reach frequently overhead, use a step-stool so that the object you are reaching for is closer to you with less shoulder stretch needed.
    • Keep the keyboard and mouse in close to the body
    • Place frequently needed items in a close work envelope between hip and shoulder height.
  • Tension and Stress
    Many people hold tension in their shoulders. When feeling stressed, try to break the cycle by practicing diaphragmatic breathing techniques or taking a quick break away from the demanding situation. Perform some shoulder rolls emphasizing the backwards and downwards movements.
  • Exercise
    • Stretch frequently throughout the day.
    • Take frequent micro-breaks.
    • Try these exercises to recreate muscular balance in the shoulder complex. Remember, these exercises should not cause pain. Start slowly using a light weight. Add additional weight and repetitions gradually.
      • Strengthen the Rotator Cuff with Side-Lying External Rotation
        • Hold a light weight in your right hand. Lying on your left side, hold your right elbow tucked in at your side. Not moving the elbow away from your side, lift your hand towards the ceiling, then smoothly and slowly move your hand towards your stomach. Repeat 8-12 times. Perform 1-2 sets. Repeat with the other arm.
      • Stretch the Pecs with the Doorway Stretch
        • Stand in a doorway facing the doorway jam. Bend your elbow placing one forearm along the doorway jam with the hand at about head height. Slowly rotate your body away from the doorway jam until you feel a nice stretch in your chest muscle close to your shoulder. Hold for 20-30 seconds. Repeat 2-3 times. Repeat with the other arm.
      • Towel Stretches for Internal and External Rotation
        • Drape a towel over your left shoulder holding to the upper end of the towel with your left hand. Place your right arm behind your back and grab on to the end of the towel. With your left hand, pull your right hand up along the spine as if you are trying to scratch an itch as high up your back as possible. Hold for 20 seconds. Repeat 2-3 times. Then with your right hand, pull the towel down, stretching the left hand along the spine as if you are trying to scratch an itch as low on the back as possible. Hold for 20 seconds. Repeat 2-3 times. Repeat with the other arm.
      • Shoulder Opener
        • Lie on a Foam Roller with the spine and heal supported and the arms relaxed at your sides. Support the arms with pillows if needed. Let the shoulders roll back around the foam roller. Stretch for a minimum of 3 minutes. Perform diaphragmatic breathing while stretching.