Pain-Free Mousing

When performing ergonomic assessments, the main factors that I have found that contribute to mousing pain include:

• Mouse Positioning
  
• Mouse Movement
  
• Muscular Tension When Activating the Mouse
  
• Forearm Positioning on the Mouse

Here are some tips to help reduce your risk of developing a repetitive strain injury or tendonitis from mouse use.

MOUSE POSITIONING

Causes of Pain

• Reaching forward for the mouse onto a desk that is higher than the keyboard.
  
• Reaching for a mouse placed to the far side of the keyboard.
  
• Planting the wrist down and swiveling the mouse using wrist motion.

Tips for Preventing Pain

• Position the mouse in a more comfortable and ergonomic location
  
  • Use an attachable mouse holder that adjusts to fit over numerical key pad (if you do not use the 10-key) or as closely to it as possible.
    
  • Or use a keyboard bridge over the numerical keys if you do not use the 10-key portion of the keyboard.
    
  • Or use a keyboard station such as the Contour Roller Pro which has a rollerbar mouse that is positioned immediately below the space bar of the keyboard.

MOUSE MOVEMENT

Causes of Pain

• Excessive wrist or arm movement when activating the mouse.
  
• Planting the wrist down placing pressure against the carpal tunnel.
  
• The wrist bent backward (estended) when using the mouse.

Tips for Preventing Pain

• The mouse should be at about the same level of the keyboard and positioned as closely to the keyboard as possible.
  
• Avoid reaching forward, up, or out to the side when using the mouse.  Position the mouse to avoid these movements (see mouse positioning tips).
  
• Activate the mouse by using small movements from the shoulder and elbow muscles rather than the wrist muscles.

Ergonomics

• Keep the shoulders relaxed.
  
• The elbow should be held loosely at the side in a direct line under the shoulder.
  
• The wrist should be held in a neutral position (not bent forward or back or angled to one side or the other).
  
• Do not plant the wrist down on that desk or on a wrist rest.  Glide the wrist over surfaces always maintaining the neutral position.

MUSCULAR TENSION ACTIVATING THE MOUSE

Causes of Pain

Forcefully squeezing the mouse between the thumb and small finger.

Forcefully activating the mouse buttons or switches.

Tips for Preventing Pain

• Hold the mouse as lightly as you can while still maintaining control.
  
• Keep the fingers held loosely against buttons and switches, not floating tensely in the air.
  
• Do not pound mouse buttons or forcefully squeeze switches.  Use only the lightest force necessary to activate controls.
  
• Using a wireless mouse can eliminate the tension of pulling against the cord (even these small tensions add up by the end of the day).
  
• Use a mouse and mouse pad that can be switched easily from right to left hand to share the work load between the two hands.
  
• A keyboard station such as the Contour Roller Pro that incorporates a rollerbar mouse eliminates the need to hold the mouse.
  
• Research mousing options such as the NoHands foot-activated mouse or a head-activated mouse placed in a baseball cap.
  
• Perform forearm and wrist stretches throughout the day.
  
• Gently stretch the thumb into the “hitch-hiking” position.

FOREARM POSITIONING

Causes of Pain

• The forearm rotated into the palm-down position for long periods of time.

Tips for Preventing Pain

• Vertical mice are good choices as the “hand shake” position with the forearm neutral rather than palm down can relieve forearm stress.
  
• Stretch into the palm-up position throughout the day.

Related Articles

Ergonomic ABCs

The Wrist and Repetitive Strain Injuries

DeQuervain’s Tenosynovitis – Repetitive Strain Thumb Pain

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.

Samples of Products Mentioned in this Article

Epicondylitis

Epicondylitis is pain at either side of the elbow where the finger and wrist muscles originate at the bony bumps of the humerus (upper arm bone). 

Although frequently mistakenly thought of as a tendinitis, epicondylitis is caused by the accumulation of microscopic tearing and damage.   The gradual accumulation of tearing and scarring that can be caused by repetitive trauma initially causes inflammation;  However, eventually, as the body is unable to heal the build-up of daily injury, the condition changes from one of inflammation to one of degeneration.  A physical change in the cellular structure of the tendons occurs including disorganization of the collagen fibers, calcifications, and loss of blood flow to the area. 

The proper classification of this injury is a tendinosis, a failed healing of microscopic tissue tears.  This can become an important distinction in prevention and healing of these injuries.  In the early stages, treatments for inflammation such as the use of cold packs and the use of anti-inflammatory medications may be helpful.  In the later stages, however, the goal may be to improve circulation to promote healing in addition to specific conditioning exercises to help organize the tissues around the elbow.

Tennis Elbow

• Lateral epicondylitis, commonly described as tennis elbow, is caused by injury to the outside edge of the elbow. 
  
• The damage is specific to the tendons of the muscles that straighten the fingers, pull the wrist back, and turn the palm up. 
  
• Only 20% of lateral epicondylitis is caused by actually playing tennis.

Golfer's Elbow

• Medial epicondylitis, or golfer's elbow, is caused by injury to the inside edge of the elbow.
  
• The damage is specific to the tendons of the muscles that close the fingers, bend the wrist forward, and turn the palm down.
  
• Golfer's elbow occurs only 10-20% as frequently as tennis elbow.

SYMPTOMS

Classic Symptoms

• Tenderness at the sides of the elbow over the bony protuberances. 
  
• Localized swelling at the point of tenderness.
  
• Pain may radiate from the elbow down the forearm and into the upper arm in more severe cases. 
  
• Activity increases pain. 
  
  • Tennis elbow is aggravated by gripping objects with the wrist bent backwards. 
    
  • Golfer's elbow is aggravated by gripping objects with the wrist bent forward.

Other Possible Symptoms

• A loss of full elbow and wrist motion because of pain.
  
• A feeling of weakness in the arm muscles because of pain.
  
• Generalized swelling of the elbow.

COMPUTER-RELATED CAUSES OF EPICONDYLITIS

One of the most common causes of tennis or golfer’s elbow for computer users can be positioning of the mouse.  

• Reaching forward for the mouse onto a desk that is higher than the keyboard.
  
• Reaching for the mouse placed to the far side of the keyboard.
  
• Gripping the mouse tightly while using wrist motion to activate.
  
• Planting the wrist down and swiveling the mouse using wrist motion.

OTHER OFFICE-RELATED CAUSES OF EPICONDYLITIS

• Reaching frequently for the phone or to take heavy manuals or binders down from high shelves.  
  
• Pulling thick files out of densely packed cabinets or drawers.

CAUSES OF EPICONDYLITIS RELATED TO TRAVEL

Those using laptops or traveling frequently on business are also at high risk.

• Carrying heavy objects such as a suitcase, briefcase or back pack.
  
• Lifting these objects onto surfaces with the palm down and the elbow straight (such as swinging them onto the security table at an airport).

PREVENTION FOR COMPUTER, OFFICE & TRAVEL RELATED CAUSES OF EPICONDYLITIS

Mouse use

• Activate the mouse by using the shoulder muscles. 
  
• The mouse should be at about the same level of the keyboard and positioned as closely to the keyboard as possible. 
  
• Don’t reach forward or out to the side. 
  
• The shoulder should be directly positioned over the elbow.  Keep the shoulders relaxed.
  
• Hold the mouse lightly.
  
• See Ergonomic ABCs for additional information.

Mouse Positioning 

• Use an attachable mouse holder. 
  
• Or use a keyboard bridge over the numerical keys if you do not use the 10-key portion of the keyboard.  
  
• Or use a keyboard station such as the Contour Roller Pro which has a rollerbar mouse that is positioned immediately below the space bar.

Mouse Style

• Use an ergonomic mouse.
  
• Vertical mice are good choices as the “hand shake” position with the forearm neutral rather than palm down can relieve stress on the tissues . 

Office & Travel Tips

• Avoid repetitive and strong gripping, especially with the elbow straight.  (for example, move the heavy manuals and binders down off the high shelves of the computer desk).
  
• Place frequently used objects within easy reach (between eye and hip level and within an easy arm’s reach to prevent excessive stretch).
  
• Use a wheeled suitcase, laptop or backpack.
  
• When using a backpack, place both arms through the straps to distribute the weight evenly across the back.  This takes the stress off the arm.
  
• Pack lightly.  Take only the needed laptop accessories to lighten the load.

General Tips

• Use both hands when lifting to share the load between the arms. 
  
• Keep objects in close to the body. 
  
• Use the strong leg muscles to help with the lift, not the back.
  
• Try to lift heavier objects with the palms up (as if you are scooping up the object).
  
• Take micro-breaks and rest the arms during repetitive or stressful activity.  
  
• Stretch often.
  
• Use heat for comfort, to improve flexibility and to increase blood flow.
  
• Use cold for inflammation or acute injury.

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.

Samples of Products Mentioned in this Article

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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.

 

 

The July issue of Shape Magazine

The July issue of Shape Magazine offers these tips for achy hand muscles caused by computing or PDA overuse -

For $$$ you can receive the BlackBerry Balm Hand Massage at Hyatt Hotel and Resorts' or the BlackBerry Thumb Conditioning Treatment at the Spa at Camelback Inn in Arizona. I am sure that many other hotels and spas will be offering similar services in the near future.

For fewer $$, perform your own spa treatment. Shape recommends massaging the sore areas with a mint lotion or hand cream. The mint soothes the muscles while the massage increases circulation bringing fresh blood flow and oxygen to the strained muscles. Stretch afterwards by placing the hand flat on the table and spreading the hand and thumb open wide. Another good stretch is to pull the thumb back gently using the other hand.

For more information on preventing hand pain with BlackBerry use, see PDA and SmartPhone Ergonomics at the Ergonomics Site at BellaOnline.

Cubital Tunnel

Everyone now knows about carpal tunnel syndrome. The term has become a mainstream name. Carpal tunnel syndrome is the most commonly occurring nerve compression of the upper extremity. It can cause numbness in the thumb, index finger, middle finger, and partially in the ring finger. It can cause weakness in the muscles at the base of the thumb and cause pain that radiates up the arm into the shoulder and neck. Like the older sibling who gets blamed for all wrong-doing, carpal tunnel syndrome has become synonymous with all hand pain.

Lurking in the shadow of carpal tunnel syndrome's fame is its counterpart, cubital tunnel syndrome. Cubital tunnel syndrome is the second most commonly occurring nerve compression of the upper extremity. It is caused by the ulnar nerve becoming pinched at the elbow. When you hit your "funny bone", you are actually hitting this nerve. The ulnar nerve is responsible for sensation in the small finger and partially in the ring finger. Trauma to the ulnar nerve can cause pain in the small finger side of the hand that radiates into the forearm towards the inside of the elbow. It can cause weakness to the small muscles in the hand and, if severe, loss of coordination.

It is time to bring cubital tunnel syndrome out from behind carpal tunnel syndrome's shadow and into the light. If diagnosed correctly, there are simple modifications that can be made to help relieve the symptoms of this frequently overlooked nerve compression.

Avoid bending the elbow for any length of time. This stretches the nerve tautly through the cubital tunnel. Activities that can irritate the nerve include:

sleeping with the elbow bent - use pillows for support; wrap an ace wrap or towel loosely around the elbow to keep it from bending; avoid sleeping on the arm or sleeping with the hands positioned up behind the head.

holding a phone to the ear - use a head-set.

blow-drying hair.

driving - adjust the seat position so that the elbows are open and relaxed; avoid resting the arms on the elbow supports or window sill.

computer work - position the height of the keyboard and mouse so that the elbows are open a bit more than 90 degrees.

playing the guitar (because of the positioning of the fretting hand) - warm-up prior to playing, take frequent breaks, stretch often.

Don't lean on the elbow.

Don't lean on the forearm, especially if it is placed over the hard edge of a desk or table. Place a soft support or cushioning under the forearm.

Position the mouse and the keyboard in front of you so that you do not need to reach forward or out to activate them.

The mouse and keyboard should be low enough that the shoulders are relaxed.

Activate the mouse by keeping the wrist solid and using shoulder movement for positioning.

Keep the wrists neutral. The wrists should be flat over the keyboard, not bent forward or back. The wrists should not be angled towards the small finger while typing. Using a split keyboard or a vertical mouse may help position the wrists correctly and relieve tension in the forearms.

Avoid repetitive elbow bending and straightening.

Avoid over-developing the triceps during gym and sports activities.

The ulnar nerve runs from the side of the neck, into the armpit, down the arm, through a groove on the inside aspect of the elbow, into the forearm, and into the hand through a small tunnel adjacent to the carpal tunnel (Guyon's canal). In addition to being vulnerable to forces at the elbow, the nerve is vulnerable at the level of the wrist. The following activities can cause an irritation of the ulnar nerve at the wrist:

heavy gripping

repetitive wrist and hand movements

performing activity with the hand bent down and angled toward the small finger

compression on the small finger side of the wrist (for example, cyclists who lean onto the handlebars, heavy machine operators and use of jack-hammers, weight-lifters, use of crutches, typists who rest the wrists on a hard surface)

Here are a few more tips to protect the nerve at the wrist.

Avoid leaning on or placing pressure against the wrist.

Do not use the base of the hand as a "hammer" (as when snapping a hubcap into place or freeing up the last remnants of smoothie from the blender).

Use vibration-reducing, gel-lined gloves when performing sports or work activities that can compress the nerve

As with other injuries, it is important to:

take frequent breaks when performing repetitive work.

gently stretch the forearm muscles.

warm-up prior to performing strenuous activity.

avoid or modify activities that cause pain.

use cold packs to control post-activity pain when necessary.

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

Recommended Ergonomic Products

The Microsoft Natural Ergo Keyboard positions the wrist in a neutral position. An added bonus - it has a detachable support that allows you to angle the keyboard in a negative tilt (or reverse slope) which can ease strain in the wrists and forearms.
Microsoft Natural Ergo Keyboard 4000

The Evoluent Vertical Mouse fits comfortable in the hand and reduces forearm stress by placing the arm in a more neutral rotation. Evoluent VerticalMouse 2 - Optical Computer Mouse

These Fox cycling gloves have gel padding in the palm and fingers for protection and comfort.
2006 Fox Reflex Gel Cycling Glove