- Don’t squeeze the mouse too hard. Keep a loose grip.
- Don’t swivel the wrist while using the mouse. Move through the shoulder and elbow.
- Keep the wrists neutral. And try going vertical (with a vertical mouse).
- Don’t reach up or outward for the mouse. Keep it on the same level as the keyboard and keep it in close.
- 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.
- Type lightly. Keep the fingers relaxed. Float over the keyboard.
- 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.
- Avoid the rounded shoulder and forward head posture. Sit properly with the ears, shoulders and elbows in vertical alignment.
- Place the monitor at eye level so you don’t strain the neck and shoulder muscles by looking down at the screen.
- 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 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.
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.
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.
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.
- 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.
- 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.
- 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.
- 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.
- Frequently look away from the screen and look at an object far in the distance. Follow the 30-30-30 rule.
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.
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.
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.
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.
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.
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
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.
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.