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H.j. Woltring, Fax/tel +31.40.413 744
07-26-1992, 10:25 AM
Date: Sat, 25 Jul 1992 10:02:45 EST
From: mark sheehan
Subject: Long article on carpal tunnel syndrome
Sender: Health effects of computer use

Here's a long article from TidBITS, an electronic journal for Macintosh
users. (For more information on TidBITS send me personal e-mail:
sheehan@indiana.edu or sheehan@iugate.bitnet). It's generally informative,
though not what I'd call authoritative. I think it could spin off
several discussions on this list.

-Mark

===========================
From: TidBITS#134/20-Jul-92
===========================

Copyright 1990-1992 Adam & Tonya Engst. Non-profit, non-commercial
publications may reprint articles if full credit is given.

Carpal Tunnel Anonymous
-----------------------
Hi. My name is Adam and I have carpal tunnel syndrome. It's a bit
hard to talk about at first, especially for us guys because carpal
tunnel syndrome (CTS) is not a real guy injury. Guys break bones
parachuting from hang gliders onto oil rigs and the like. Guys do
not get pains in their hands, wrists, and arms from typing a
little too much while sitting in a bad chair.

Well, yes they do. So do women. Face it, if you are reading this
on a computer then you may be at risk for CTS or some other
repetitive strain injury. Perhaps the hardest part of dealing with
these injuries is admitting that you have them. Tonya has a
related problem, tendinitis, in her wrists, and after she admitted
publicly at work that she couldn't do as much as she'd like, a
number of colleagues came over individually and said that they too
had occasional wrist pain. And this is from people who talk on the
phone six hours a day (using headsets).

The first thing to do is to immediately send this issue to anyone
you know who might be suffering from CTS or a related injury. I
mean it. The State of Washington Department of Labor estimates
that symptoms of carpal tunnel syndrome will develop in 10% of all
employed adults in Washington sometime during their employment
careers. Surveys of doctors suggest that these sort of injuries
are now the major occupational hazard of the Information Age.

It's also expensive, for you or your insurance company, if you
don't treat it immediately. A study by the American Physical
Therapy Association claims that a mild case of CTS can cost
between $5,000 and $10,000 in medical care and lost work time, and
a serious case that requires surgery on both hands can cost
$100,000. If you have bad furniture at work that hurts your
wrists, statistics like the one above can help convince even the
stingiest employer to replace it. After all, your employer will be
paying the worker's compensation and a good bit of your health
insurance premiums.

I'm not going to explain CTS in detail because that's best
explained by a book on the subject or an unusual doctor with time
to talk. The basic idea is that several tendons and the median
nerve pass through the carpal tunnel, formed by three bones and
some tough cartilage, in the forearm and wrist. When you
repeatedly bend the wrist at bad angles, you irritate those
tendons and the nerve. Irritation leads to inflammation, which in
turn leads to more irritation since the carpal tunnel doesn't have
much extra room and the inflamed tendons rub on each other and on
the nerve. We're talking about vicious cycles.

CTS manifests itself in pain from the thumb and next three fingers
(another nerve serves the little finger) all the way up to the
elbow. We've found that overcompensation and stress can also cause
pain in the shoulder, neck, and back, and it might even cause
migraine headaches if you're unlucky. The pain can range from
minor itching and stiffness (that's how bad I've got it) to
flaming shots of white-hot pain searing up and down the fingers
whenever you move them. Buttoning a shirt becomes impossible and
sleep may as well. What can you do? Read on.


Carpal Tunnel Help
------------------
I'm not a doctor, but I've seen one and have researched this
subject, searching for more information on ways of avoiding CTS
and curing it once it has happened. If you believe that you have
CTS, please go see a doctor right away, or at least after reading
what I've written below. I concentrate on the easy things you can
do, in part because they're cheap and easy, and in part because I
feel that they are in the long run more effective than the drastic
invasive measures that a doctor may recommend as a last ditch
effort. Do note that the measures listed below are not in any
specific order because I think they're all important, and none
conflict with each other, unless you go under the knife.


Ergonomics
The first thing you should do to prevent or treat CTS is to make
sure that your computer environment is well-set up, ergonomically
speaking. The basic principle involves right angles. Your feet
should rest flat on the floor, your calves should be perpendicular
to the floor and to your thighs, which should be parallel to the
floor, and the angle between your thighs and back should be at
least 90 degrees. Your arms should hang relaxed at your sides, and
your forearms should project out straight in front of you, forming
another 90 degree angle. Your wrists should be straight, not
arched upward. You might adjust your keyboard for this, or you
might have to adjust your chair and desk height. Standard typing
height is supposedly 27 inches, but that will vary with your
height. I had to saw an inch or so off my desk and buy an
adjustable chair, both of which helped a great deal.

You should be between 18 and 28 inches from your screen, and it
should be adjusted so that it is between 15 and 30 degrees below
your straight-ahead line of sight. If the screen is much lower
than that, you'll probably end up slouching.


Wrist Pads
By now you've probably seen the neoprene wrist pads that many
people put in front of their keyboards. I highly recommend you buy
one (about $10) because they help in two important ways. First,
when you type, you shouldn't rest your hand on the desk, but many
people do. The wrist pad is designed to remind you to lift up
slightly so your hands don't rest on any surface as you type,
because that angle can compress the carpal tunnel. Secondly, when
you stop typing to think, you probably put your hands down, and
it's better to rest them on a soft pad than on the hard corner of
a desk, which can cut off circulation and compress the carpal
tunnel.

I'm convinced that these pads, simple as they are, help a great
deal. Microsoft gives a wrist pad to every employee. Microsoft's
wrist pads are unimpressive compared with the one I've been using
from Silicon Sports. Generic wrist pads consist of a piece of
neoprene or similar rubber padding, whereas Silicon Sports has a
better design with two layers of padding under the colorful top
covering. The lower layer is the standard dense foam rubber, but
the thinner layer on top is a softer foam than the generic pads
use, and I found it noticeably more comfortable. Silicon Sports
also has a pad for the PowerBooks coming out soon and a clever
wrist pad/mouse pad combination that fits together like puzzle
pieces and keeps everything compact. Get one of these wrist pads
and use it. Depending on your office-mates, it might also be good
for whacking them on occasion. (Kids! Don't try this at home!)

Silicon Sports -- 800/243-2972 -- 415/327-7900


Chill Out I
Take a break and relax. I suspect you work too hard and put in too
many consecutive hours at the keyboard. You should take a break
every 45 minutes or so, and by a break I mean that you should
actually do something different, like go hang around the water
cooler or hassle a coworker (Dan Quayle's Council on
Competitiveness will have me shot for that statement.). You can do
some simple exercises as well, the easiest of which are (a) gently
squeezing a rubber or foam ball in your upward-facing palm and (b)
extending your fingers completely until you feel a stretch, then
relaxing your fingers and curling them in toward your palms.


LifeGuard
Visionary Software has a useful little DA called LifeGuard that
can nag you into actually taking these breaks. It monitors how
long you're typing or mousing, and then tells you to take a break.
You set the length of both the work time and the break time, and
it will give you either an audible reminder or a dialog reminder
that suggests something else (which you can set) to do. LifeGuard
also has a useful section on exercises (including the ones
mentioned above) and another one on ergonomics. Lifeguard has a
number of limitations, and I'd far prefer it if you could pick a
set of sounds for it to choose from randomly and if it had an
option to literally lock the screen to kick you off, but it's cute
and useful.

Visionary Software -- 503/246-6200


Splints
One of the easiest things you can do that a doctor will also
recommend is to get wrist splints and wear them in bed, if not
also during the day. Most drugstores should have them in different
sizes and shapes, although all the ones I've seen are a vague tan
color. I'd like to see them in black, bright blue, and even
perhaps some fluorescent colors. There's no reason they have to be
ugly, and it would be nice if their velcro wasn't quite so
exposed. I hate sticking to everything!

The splints are generally called "cock-up splints" or something
similar because the metal splint cocks your wrist at a 20 to 30
degree angle. This position is neutral, so in theory you aren't
compressing the carpal tunnel while wearing them. I also find that
certain life activities, like driving a car without power steering
or pushing a shopping cart, are extremely hard on damaged wrists.
The wrists splints provide welcome support in those cases, but I
do wish they didn't look so stupid.


Vitamins
My doctor recommended that I take vitamin B6. Apparently the
omniscient "they" have done studies showing that vitamin B6, in
doses of 100 mg daily, can help cure CTS. Apparently B6 plays a
role in producing neurochemical transmitters, and that can help.
You can find B6 naturally in brewer's yeast, wheat germ, and
blackstrap molasses, but if you're like me, your diet doesn't
include those three items regularly. Supplements are probably in
order.

Another vitamin that _may_ help is vitamin E, in 400 IU doses
before bed. My doctor mentioned it as well, and my father had
excellent luck with it clearing up his arthritis in his mid-
thirties. I've taken it on and off when I'm running competitively
because I find that I tend to get shin splints otherwise. Medical
science is still undecided about vitamin E, and the only things
they've proven, I believe, are that it reduces free radicals (a
laudable goal) and it prevents impotence in rats (an equally
laudable goal).


Chill Out II
This time I mean it literally. Current medical thought believes
cold is much better than heat for aiding healing. The basic idea
is that cold reduces inflammation, whereas heat may reinforce it.
Also, since nerves are extremely sensitive to heat, heating aching
hands may feel good, but it's deceptive because all that's
happening is that the nerves that were transmitting pain impulses
are now sending heat signals.

Probably the best way of applying cold to your arms is via ice
massage. If you freeze water in paper cups, you can then rub your
arms with the frozen cup, gradually tearing the cup away as the
ice melts. It's messy and not terribly ecologically-conscious, but
it works and lots of athletes use it to reduce pain and swelling
after exercise.

A tidier method is to go to a sports store and pick up four or
five of those ice bags that have some sort of blue gel in them.
They're cheap and they work well. Don't overdo the cold. Frostbite
isn't fun.


Massage
Gentle massage on the hands, wrists, arms, and shoulders (which
may often be tight and sore too), may feel good, especially if
someone else does it, and you can also use a hand lotion that has
vitamin E in it, just in case some vitamin E is absorbed through
the skin. No clue if that's true, but I've had good luck with
using it in massage.


Exercise
When I first admitted that I had CTS, I thought a bit about what I
could do that doesn't involve my hands. Other than being a couch
potato, which I don't approve of, all I could think of is running.
It was an excellent excuse to get out on the trails regularly. My
doctor agreed that exercise was excellent, in part because it
doesn't use the hands, and in part because it helps relax both the
body and the mind. I'm not going to recommend that you all
immediately become distance runners, but exercise-induced
endorphins are good stuff (now I'll have a drug czar on my case).

Standard warnings about overdoing it apply here too. You may not
think about it normally, but if you're having trouble with your
hands and wrists, be careful not to clench your fists when you
run, and avoid shaking your hands at the wrist. Of course, walking
is good, and swimming may be, although I find that it tends to put
a bit too much pressure on my wrists, depending on which stroke I
use. Bowling is right out.


Alternative input devices
Definitely look into alternative input methods that will reduce
strain on your hands and wrists. The most common of these devices
is the trackball, and next week we'll look at two well-designed
trackballs, the CoStar Stingray and the Curtis MVP Mouse and
Footswitch. Trackballs are often more comfortable because the
mouse click & drag action requires a significant downward
pressure, and that pressure requires additional force to move the
mouse horizontally. Also, moving the mouse with your wrist and arm
is more likely to compress the carpal tunnel than similar
movements with a trackball, which requires only the use of the
fingers.

More esoteric input devices include chord keyboards and voice
controllers. Chord keyboards may help reduce CTS problems because
you don't have to move your hand at the wrist to reach all the
keys. A chord keyboard arrays its small number of keys so your
fingers are always on the correct keys, and all you have to do is
press the proper combinations. It may sound awkward, but I'll bet
it took you more than an hour to learn to touch type on a standard
QWERTY keyboard. We'll have more on Infogrip's BAT chord keyboard
in a future issue, and you can get more information from the files
stored on our fileserver.

Voice controllers are definitely neat, but they must be trained,
are sensitive to changes in your voice, and can only do the sort
of things you can do with QuicKeys. The Voice Navigator demos are
impressive, with the slick salesman quickly drawing their logo by
voice. He sounds like he swallowed an auctioneer. However, the
problem is accuracy, not speed. Apple's Casper technology promises
to be pretty snazzy when it ships with the next generation of
high-end Macs, but I'm not holding my breath. Finally, none of
these systems will do dictation - for that you need a costly
speech recognition system.


Simple Drugs
Doctors will recommend aspirin or ibuprofen early on. They may
also provide a prescription for more potent stuff like Feldene,
which is much stronger and has more side effects. Remember, drugs
merely treat the symptoms, and unless you're in a situation where
the symptoms prevent the body from healing itself, drugs may
provide only temporary relief. You can't take this stuff for the
rest of your life.


Relaxation
OK, you've read all of my suggestions, but I will venture into
left field here and claim that none of it will help unless you
reduce your stress level. Since I've had CTS, I've talked to a
number of people who have successfully defeated it in interesting
ways. One swears by Tai Chi, a martial art that involves slow,
deliberate movements and heightened consciousness of your body.
Another had CTS so badly that they hospitalized him and gave him
morphine for the pain. Surgery cured the CTS, but didn't reduce
the pain. It wasn't until another doctor put him on a stress
reduction program that he started to recover.

Another name for CTS-type injuries is cumulative stress injuries
because you are essentially stressing a certain part of your body
thousands of times an hour, and the body can't handle the stress.
Mental stress will cause physical reactions as well, and the guy I
spoke of above who had surgery didn't experience reduced pain
until he was able to relax and break the stressful mental pathways
he'd built up.

Support for this theory also comes from a study showing that early
symptoms of CTS were twice as a common among communications
workers who were electronically monitored than those who weren't,
possibly because of lower stress levels in unmonitored workers.

I suggest that you can and must reduce your stress level to allow
your body to heal. From what I've read and heard, you have a
variety of choices on how to go about this, be it yoga, Tai Chi,
meditation, a non-violent martial art, or even acupuncture. I
suspect it will be hard for many of you, being rational computer-
types like me, to try one of these methods wholeheartedly,
although I gather people become much more accepting when the
alternative is the knife. I also highly recommend that you look
for a book called "Freedom From Stress: A Holistic Approach" by
Phil Nuernberger (ISBN 0-89389-071-5). It combines well-explained
scientific evidence along with advice on ways to reduce stress
using the theories of yoga as a base. Do with that advice what you
will - I'm trying it.


Icky things
I don't want to talk about this much, but if you let wrist pain
progress too far, Western medicine will almost certainly want to
give you drugs or cut you open The first move is a cortisone
injection into the wrist. This is painful and doesn't always work.
Doctors generally try injecting you up to three times at intervals
of three weeks. If you're lucky, the pain will recede by three
days after the injection. Some people have great luck with this
treatment. Others don't.

If you're not lucky, you progress to surgery. The basic principle
is that the doctor can release the pressure in the carpal tunnel
by slitting it so that it can expand slightly. Some people do well
after this process and return to normal work several months later.
However, if you don't treat the causes of CTS, you can just get it
all over again. So do yourself a favor and try the stuff I suggest
above wholeheartedly before you submit to the needle and the
knife. It can't hurt, and I sincerely hope it helps a great deal.