Wednesday, March 12, 2008

Ergonomic Process - When it Goes Bad

Last week I had the opportunity to work with several injured workers in their office environment. Both spend 8 hours in front of a computer performing extensive keyboard and mouse work. Both are in serious pain with repetitive injuries that cause aching within 30 seconds of sitting down to work. Both have seen doctors, therapists, and had ergonomic interventions with the best equipment issued. One has already been scheduled to undergo a carpal tunnel release in the near future.

Speaking to and observing the work habits of these women has affirmed my belief that ergonomics is a multi-faceted process requiring teamwork to be successful.
  • The doctor may diagnose and offer expertise in prescribing medications to calm down the inflammatory process of injury.
  • The therapists can perform modalities such as massage, ultrasound and the use of heat and cold to promote injury recovery. Skilled in observing how bodies work, they can discover areas of weakness, tightness and muscular imbalances that can be corrected with therapeutic exercise.
  • The ergonomic specialist can provide the equipment, work-site modifications, and work-style recommendations that create a comfortable and less stressful working environment.
  • Management can provide a supportive environment that allows healing, promotes employee good-will, but also ensures productivity.
  • And the injured worker needs to believe in the program and take an active part in their recovery. This is not always an easy thing to do – it requires persistence, even a bit of obsession, to attend medical and therapy appointments, take medications on schedule, change work habits, stretch, take frequent micro-breaks, and use cold packs throughout the day – all while trying to get the job done, frequently under the microscope of management and co-workers who may not believe that an invisible injury can be so painful.

If any aspect of the team process is impaired, recovery may be impaired. Communication and education are critical throughout. So is observation, follow-up, and accepting feedback. My observation of the two young women last week shows how the process can break down in spite of good intentions. It also highlights one of my ergonomic pet peeves – the wrist rest.

Both women had wrist rests in place, and both demonstrated their typing skills using the wrist rest, believing that they were using them correctly and showing me what I wanted to see. Neither had received instruction in the proper use of the wrist rest and they were probably continuing to create inflammation through its improper use.

The wrist rest is not inherently a bad piece of equipment, but it is improperly named. Logically, because of the name, most people feel they need to rest their wrists. Most plant their wrists down on the nice soft surface while typing and feel they are doing a good thing - an ergonomic thing - that will help them prevent injuries. In actuality, they are isolating the work of the fingers from that of the upper arm.

The finger muscles are too small and weak to perform constant movement throughout the day. In addition, the isolated movement is often more extreme than typical to make up for the loss of positioning movement over the keyboard often performed by the shoulder. As the muscles of the fingers and wrist originate at the elbow, pain often begins radiating from the fingers into the elbow.

If ergonomic equipment is issued without warning, - I’ve worked with employees who just showed up one morning to find their work environment changed and ergonomic equipment in place - consent, or instruction in the proper use, it will either be rejected or used in what is thought to be the correct manner. However, the equipment itself is not the answer, but only a tool that enables a worker to be safe if it is used properly.

It would be much better to call the wrist "rest" a wrist "guide" as the wrist should float over it. The wrist rest should "guide" the wrist into the neutral position. It is okay to rest down lightly during typing breaks.

Here are some additional ergonomic keyboard work-method recommendations.
  • The hand should be positioned over the keyboard using small shoulder and elbow movements.
  • The shoulders should be relaxed and not elevated (drawn up towards the ears).
  • You should be in close enough to the work surface so that your ears, shoulders and elbows are in line.
  • The work surface should be low enough that the elbows are open slightly greater than 90 degrees.
  • The fingers should be relaxed and slightly curved as if resting over a ball.
  • Hit keys lightly with only the minimal amount of force necessary to activate the keys.
  • Don’t hitch-hike by holding the thumb tensely over the spacebar.

Marji Hajic is an Occupational Therapist and a Certified Hand Therapist practicing in Santa Barbara, California. For more information on hand and upper extremity injuries, prevention and recovery, visit Hand Health Resources.

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Wednesday, March 05, 2008

What is Writer's Cramp?

Technically, “writer’s cramp” is not an overuse syndrome.  Writer’s cramp is a problem of incoordination and loss of control of movement arising in the basal ganglia of the brain.  Its cause is unknown.  The symptoms are localized, sustained muscle contractions that cause twisting and repetitive movements or abnormal postures when a person performs a specific, fine motor task such as writing.  Pain and cramping is uncommon, although discomfort in the forearm wrist and fingers may be present.  (Sources:;


Although true writer’s cramp is a rare syndrome, hand pain, muscle fatigue and cramping from repetitive writing is not.  Even if writing is not a large part of the job, writing can contribute to the development of repetitive strain injuries.  Forceful gripping of the pen and pressing the tip onto the paper, awkward positioning of the pen or the paper, contact stress from holding the pen or leaning on the wrist or forearm are all risk factors of musculoskeletal disorders.  In addition to addressing the keyboard and mouse as contributing factors to hand, wrist and forearm pain, writing technique should also be considered.


As early as 1700, Bernardino Ramazzini, considered to be the founder of occupational and industrial medicine, wrote that "the incessant driving of the pen over paper causes intense fatigue of the hand and the whole arm because of the continuous . . . strain on the muscles and tendons." (Source: 

In 1995, almost 300 years after Ramazzini described the occupational hazards associated with writing, the first ergonomic pen was introduced to the mass market.  The Dr. Grip pen, with a rubberized and wide-body barrel was designed with the purpose of increasing writing comfort.

Several other wide-body pens followed quickly thereafter including the PhD and the BIC XXL.  All of these styles followed the quill, stick-style design.

Recently, the ergonomics of writing have been addressed with alternative pen designs that fit the hand better and reduce the pressure and tension of writing.  These pens are breaking away from the standard stick-pen look.  Such designs include the EZ Grip, the PenAgain, the RingPen, and the EvoPen.

A Review of Ergonomically Designed Pens


The following are some writing tips to reduce your risk of hand and arm pain.

To Reduce Force

  • Use the lightest grip possible while writing.  

  • Use ergonomically designed or wide-barrel pens.  

  • Use a rubberized grip or increase traction by wrapping a rubber-band around the pen barrel.  

  • Use a felt-tip pen, gel pen or roller ball so that the tip glides easily over the paper.  

  • Do not plant your wrist or forearm on the desk.   Glide over the surface of the desk using your shoulder to initiate the movement of writing.

To Avoid Awkward Postures

  • Keep the wrists neutral.

  • Position the elbow so that it is open at more than a right (90 degree) angle. 

  • Keep the shoulders relaxed.

  • Keep the hand relaxed and avoid forceful bending or hyperextension of the finger joints or thumb when holding the pen.

  • Position the paper you are writing on about 2 inches above elbow level while sitting with your shoulders relaxed. 

  • Use a sloped desk to reduce the need to bend the neck or round the shoulders forward.

  • Place the paper in a position that is easily accessible. 

  • Use a microdesk writing platform above the keyboard. 

  • Get in close to the work surface.

  • Don’t reach around objects placed on the desk while writing.

  •  Don’t hold a pen while typing. 

  • Use a headset if you need to type and speak on the phone at the same time.

To Reduce Contact Stress

  • Consider one of the new ergonomically designed pens. 

  • Use the lightest hold possible while still maintaining control of the pen. 

  • Don’t lean on the wrist or the forearm, especially on the sharp edge of a desk. 

  • Use a round, not a triangularly-shaped, rubberized grip.

  • To reduce repetitive writing movement

  • Take microbreaks.

  • Stretch often.

  • Vary work tasks.

For more information on hand and upper extremity injuries, prevention and recovery, visit Hand Health Resources.


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