ASHT News Bulletin Kids and Electronics

A majority of children are now using desk computers, hand-held electronics such as smart phones and PDAs, and gaming controls on a daily basis.  Parents should take an active part in teaching their children techniques that will help them prevent future injuries such as carpal tunnel syndrome and tendinitis. 

The American Society of Hand Therapists (ASHT) stresses the importance of developing good habits early on in children to prevent hand and wrist injuries in adulthood.  Healthy techniques learned at a young age can carry over into other aspects of life where there is a similar injury risk such as sitting in front of a computer or playing musical instruments. The ASHT Media News Bureau provided the following overall tips and health guidelines for kids and video gamers of all ages: 

Prevent Future Injuries such as Carpal Tunnel Syndrome and Tendonitis

• Tell your child to use a neutral grip when holding the controller. A neutral grip is when the wrist is straight, not bent in either direction (not strong or weak). It will allow for wrist motion in a plane where more motion is available in the wrist. 


• Ask your child to take a break every hour or switch to another activity. Overuse of repetitive motions, such as pressing buttons, can cause tendonitis of the elbow or lead to Carpal Tunnel Syndrome. 


• Don’t let your child sit back on his/her knees. Bending the knees this far is not only a hard position for the knee joint, but it requires your child to push most of his/her body weight up with his/her hands and wrists, placing increased pressure on these joints as well.


• Make sure the monitor is at the correct height.  While looking at the horizon, your child’s eyes should be looking at the top of the monitor.(this may vary if child wears glasses)


• If your child is typing, the keyboard should be at a height so that with his/her wrist/hands are straight, his/her forearms are parallel to the keyboard surface. 


• When using a GameBoy (or other hand held gaming devices), encourage your child to put pillows in their laps and rest arms on pillows. This will allow them to keep their head in a more upright position and therefore decrease neck strain.  The pillows will help support the arms so they do not have to be held up in the air.


• Whenever, possible your child should be sitting in an appropriate chair.  This would be a chair that allows your child to comfortably put their feet on the floor and also provides good back support. 


• When s/he is using a single control device (like a mouse), encourage your child to switch hands frequently.  This will allow the one hand to rest and reduce fatigue. 


• Have your child frequently focus on a distant object (away from the monitor) to help reduce eye fatigue.

The ASHT Media News Bureau is a central source for information on the specialized profession of hand therapy. ASHT members serve millions of patients nationwide, providing treatment for injuries and preventative care.  For more information about prevention technique and professional hand therapy, visit www.asht.org.
Marji Hajic is an Occupational Therapist and a Certified Hand Therapist practicing at the Hand Therapy & Occupational Fitness Center in Santa Barbara, California. For more information on hand and upper extremity injuries, prevention and recovery, visit Hand Health Resources.

ASHT Guidlines for Hand Held Devices

According to The American Society of Hand Therapists (ASHT), heavy use of hand held electronic devices can lead to hand ailments.  In this national consumer education alert - initially issued in January of 2005 and recently reissued - professional hand therapists offer tips for preventing injuries caused by the extreme use of small personal music devices, smart phones and PDAs.

The excessive use of scroll wheels and frequent text-messaging associated with portable electronic devices are causing thumb, finger and wrist pain. “We are giving our thumbs, wrists, and elbows a real workout with heavy use of hand held electronics like blackberries and iPods,” said former ASHT president Donna Breger Stanton.  Injuries such as carpal tunnel syndrome, “BlackBerry Thumb” and tendinitis are being seen with increasing frequency as the use of these popular devices is increasing.

ASHT GUIDELINES FOR HEALTHIER USE OF HANDHELD ELECTRONIC DEVICES – A SUMMARY

Respect Pain.   If you have pain while using a hand held device, stop and take a break.  Pain is the body’s warning sign that something is wrong.  Pain may be indicating that you are straining muscle groups.

Be aware of wrist positioning.  Hold the device with the wrist in a neutral position (not bent forward or back or angled to either side).  Even a small amount of wrist angulation can increase tension on the tendons and nerves.

Take a break.   Every 20 minutes or so, take a micro-break (stop the activity for one or two minutes, stretch, or switch to another activity).  Repetitive motions such as pressing small device buttons can cause inflammation of the tendons or cause nerve irritation.

Relax your arms.  If possible, place pillows in your lap and rest your arms on the pillows.  Or use the device with the forearms supported on a desk or tabletop (however, do not lean the elbows onto a hard surface or press the elbow or forearms onto the sharp edge of the desk).   This will allow you to keep your head in a more upright position than if the device is held in your lap and therefore decrease neck strain.  The pillows or desk will help support the arms so they do not have to be held up in the air.

Sit in an appropriate chair.  This is a chair that allows you to put your feet comfortably on the floor and also provides good back support.

Switch hands frequently and vary the finger being used for texting or activating the electronic device.   This will allow the one hand or other fingers not being used to rest for awhile and reduce muscle fatigue.

Don’t forget the eyes.  Frequently look away from the screen and focus on a distant object to help reduce eye fatigue.

Download the ASHT Alert

The American Society of Hand Therapists is a not-for-profit organization seeking to advance the specialty of hand therapy through communication, education, research and the establishment of clinical standards. ASHT’s 3,000 members in the United States, Canada and around the world strive to be recognized leaders in the hand therapy profession. For more information about hand therapy or to find a hand therapist in your area, visit www.asht.org.

Marji Hajic is a member of ASHT and 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

RELATED ARTICLES

PDA & SmartPhone Ergonomics

Laptop Ergonomics

PC & Video Gaming – Ergonomic Tips

Wi-itis and Other New Repetitive Injuries

Typing Styles

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 Style

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 (see book review).  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. 

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.

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.

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: www.dystonia.ie;  en.wikipedia.org/wiki/dystonia)

WRITING CAN CONTRIBUTE TO RSIs

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.

HISTORY

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: www.whonamedit.com/doctor.cfm/428.html) 

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

WRITING TECHNIQUE - ERGONOMIC TIPS

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.

 

The Elbow and RSI

Repetitive Strain Injuries (RSIs) from computer use or desk work can cause headaches, eyestrain, and pain through the neck, shoulders, arms and back. "The Elbow" is part of a series that takes a closer look at the mechanism of injury and specific injury prevention techniques for particular pain areas.

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 such as the


Heelbo® Heel and Elbow Protector.
Or use an ace wrap around a soft cushion.

 
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. For example, the Pillow Ergonomic Support.
  
• 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. Check out the Microsoft Natural Keyboard Elite
  
  
  
• Move the mouse from the shoulder, not the wrist.
  
• Take frequent micro-breaks.
  
• Stretch often.

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.

 

 

Using Ergonomics to Reduce Work Place Costs and Prevent Injuries

Using Ergonomics to Reduce Work Place Costs and Prevent Injuries



50% of all workers are at risk of developing a repetitive stress injury such as carpal tunnel syndrome or back pain. 1 in 10 will develop an injury severe enough that it interferes with work, home and leisure activities. Symptoms may include pain, numbness and tingling, weakness and clumsiness. At its worst, those who experience these injuries are unable to work, unable to pursue musical and artistic hobbies, unable to perform simple household tasks, even unable to hold and care for their babies.

In addition to the pain and disability experienced by the individual, the cost of these injuries can be tremendous. The carpal tunnel release is one of the most commonly performed surgical procedures in the United States. An individual case, including medical, therapeutic and work-related expenses, can cost up to $29,000. According to the U.S. Department of Labor, the direct and indirect costs of all these types of injuries can total as much as $20 billion dollars a year.

If we or a loved one are not personally affected, why should we care? As a consumer, for every purchase we make, for every service we need, these costs are passed on to us. As an employer, these costs have a significant impact on our business expenses and practices.

Most of us have either experienced symptoms ourselves or know of someone who has hand pain or had surgery on the hand. We see people daily, on the streets, in our offices, at the grocery stores, wearing wrist braces or back supports. Yet few of us are able to say what causes these injuries or, more importantly, to plan strategies for prevention.

Repetitive injuries occur when daily microscopic damage exceeds the body’s daily ability to repair tissues. The damage accumulates gradually until eventually we have a deficit in healing and symptoms become evident. Demanding work activity or poor work practices (such as excessive or repetitive work, forceful movements, poor posture and awkward positioning) can all contribute to the development of injuries. Anything that slows the body’s ability to heal can also contribute: stress, poor health or illness, not taking care of your body.

The earlier that repetitive injuries are treated, the better the chance of recovery. However, the very best defense is to prevent the injury from occurring in the first place.

Ergonomics is the art and science of creating comfortable and user friendly work environments and work practices. Maintaining a work environment that is ergonomically sound and developing work practices that place the least amount of stress on the body are important to preventing injuries.


This site is dedicated to ergonomic practices. It will help you look at how you perform your work tasks as well as the environment in which they are performed. It will provide you with tips to making small and inexpensive changes. For example, take steps to reduce the noise around you and maintain a comfortable work temperature. Modify activities that require awkward positioning, forceful movements and repetition. Using a glare screen and a telephone head-set, changing the position of the mouse or the monitor, and varying your tasks performed throughout the day, can all significantly reduce body stressors.


For complete injury recovery and prevention, it is important to also look at general health and fitness practices and to perform an exercise program that targets the muscles most at risk for injury. For more information, visit