You Asked for It
August 2002

This email inquiry came a couple of weeks ago:

"I currently work as a software developer and have been working with my current employer for approximately 5 months and overall in the IT field for approximately 2 1/2 years. I began noticing some discomfort about 2-3 months ago, specifically when typing and mousing in my arms, right wrist, as well as finger tips and have seen a doctor regarding the problem where I was told to take some anti-inflammatories. I feel that this solution would only be addressing the symptoms and not the underlying cause of the discomfort and potentially, ultimately, lead to further discomfort and more seriously, injury.

I have also been to a chiropractor who has helped me a great deal, however when I return to work the next day, the discomfort returns. The same thing occurs during weekends. Friday evening, the issue seems to go away and then first thing Monday morning they re-occur which again leads me to believe that my current arrangement might be somehow causing this. This is the first time I have ever experienced any sort of discomfort when typing.

It is an issue that begins from the inside of mainly my right wrist and extends up into my forearm and results in tightening of the muscles more to the top of my forearm and all up along the inside of my forearm. There is also some discomfort on the top of my wrist when I bend it down towards the floor if my arm is extended directly in front of me with the palm facing down, mainly towards the end of the motion (finger tips pointing down at the floor) but is slowly starting to go away. My left arm suffers from almost no discomfort except for some minor tingling in the finger tips every once in a while when typing. I am not a professional in ergonomics by any stretch and do not pretend to be but I can say with a reasonable amount of certainty that my present situation\arrangement is most likely not exactly optimal and was wondering what I could do to fix my current arrangement and if you could help with this?

Again, thank you very much for your time and I look forward to hearing from you,

Tony"

You haven't given me any description about your work station so I have to make a few assumptions. I am assuming that you use the computer extensively and that you use the mouse with the right hand. Judging from your web site and the pictures of the desks in the simulated offices (which may be a reflection of your own work space) I also assume that you have a corner desk with the keyboard on the desk surface. I don't know how tall you are, but on the further assumption that "Tony" is a male name, I figure that you are taller than 5'8". Lastly,as a programmer, I am assuming that you know how to type without significantly looking at your fingers.

First some comments on the history you have given me:

• Anti-inflammatories - You are correct that pharmaceuticals are mostly treating the symptoms, but I concur with your physician that they are beneficial. In conjunction with modifying how the work station is set up and used and with the other treatments you describe, the anti-inflammatories will assist the healing process. Used as the sole treatment method however, you will likely experience re-occurrences of your symptoms.
• Recovery with rest - This is typical of most repetitive strain injuries, such as flexor (palm side) and extensor (posterior side) tendonitis, which may be what you have described. The tingling in the fingertips may indicate some pressure on the a nerve and it is important to note which fingers are involved and report this to your physician.
• Left less than right - Bilateral symptoms often suggest that there may be some involvement with your neck. A chiropractor or physical therapist will be helpful to diagnose and treat this. As the nerves exit from the neck they can be compressed at the exit between the vertebrae, as they travel under the trapezius (and other neck muscles), passing through the thoracic outlet between the collar bone and first rib, in the brachial plexus of the arm-pit or anywhere there is inflammation / pressure in the arms.

And now some potential improvements... bearing in mind that I have to write in generalities, not having seen your postures or working conditions.

• Arm Posture - First, you should be sitting with your back and feet supported. Your shoulders should be relaxed, upper arms against the sides of the body, forearms parallel to the ground and wrists flat and straight. If the keyboard tray is not adjustable, you may need to raise or lower your chair and support your feet accordingly. If you need to buy an adjustable keyboard tray for your work station, I can give you the names of some local suppliers I frequently work with. Your head should be upright and looking forward to the screen to reduce loading in the neck muscles.
• Equipment Used - If your wrists are not straight (a straight line running up the forearm from the longest finger), a split keyboard may be helpful. If your hands are small, I usually recommend the Microsoft Natural Elite. For larger hands, the MS Natural or any of the look-alikes would work. To keep your wrists flat (put a ruler under your watch strap or cuff, extending to your knuckles, and there should be no gap) you may need to use a palm rest or build up some palm pads at the front edge of the keyboard. Be careful not to use these as a support but to hold your hands just above the surface, allowing them to fall onto the padded surface when pausing. At the mouse, use a mouse pad with a palm support to keep your wrist flat.
• Introduce recovery Time - This is probably the most important point I can make: use the mouse with your left hand. No, I have not lost my senses. You are equally capable of using the mouse with your left hand as with your right, you just learned it with your right first. It may take a week or so to become comfortable with using the mouse with the left hand. The keyboard is a lousy design to start with and when the mouse is on the right side you have to reach across the cursor and number keys to get to the mouse. This requires continuos strain on the neck, shoulder and arm muscles because you have to hold your elbow away from your body. Moving the mouse to the left side will not only give your right arm some recovery time by transferring some of the workload to the left side, but will allow the left arm to use the mouse immediately beside the alphanumeric portion of the keyboard. This lets the left elbow remain close to the side of the body so that the shoulder muscles remain relatively relaxed. Given the on-going nature of your discomfort, you will likely need to keep the mouse on the left even after you feel you have recovered.
• Treat Discomfort as it Occurs - you will need to purchase 2 or 3 gel ice packs and keep them in the freezer. Ice is used to treat new or re-occurring injuries. If the pain remains unchanged over days and weeks, then heat is more appropriate. But, you say that it builds up over the week and recovers after treatment and on weekends. This means that (in addition to changing your postures and some of your equipment, and taking your anti-inflammatories) you should apply ice to the sore areas 3-5 times per day for 20 minutes apiece. Wrap the gel pack in a damp tea towel or apply it through a shirt so that it is not directly on the skin. This will help control the inflammation and assist the healing process.

Feedback

Hi Sharon
I was just reading your newsletter and was interested in your reply to Tony regarding his/her right forearm and hand symptoms. It was very thorough and thoughtful. I have one comment to make regarding the chiropractic and/or physio referral. It has been my experience that more often than not, symptoms referring from the cervical or upper thoracic spine do not necessary present bilaterally. Most often they are left or right sided exclusively with minimal involvement of the opposite side.

Thanks for letting me comment. As always, I enjoy your newsletter.

Regards,

Dr. Joan Shaben
Chiropractor

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