For the Keyboard & Mouse (K&M) Athlete:

By Bruria Ginton (1997)

When, as avid keyboard and mouse users (K&Mers), we engage in heavy surfing, webite designing, and E-mailing, we may not be contending for any medals or prizes. From my point of view--as a licensed massage therapist (LicMT) who has specialized in sports injuries and with my background in organizational psychology--any highly skilled, repetitious physical activity, heavy or light, taken to the extreme has in it an element of athletics. Be it in sports, in the arts and crafts, in the hands-on healing arts, in the typical blue-collar workplace, and now in the white-collar highly computerized workplace. When our fingers and hands cover miles of daily clicking, K&Mers, therefore, like all athletes, must stay "in shape," for we too run the risk of injury. And the most likely injury resulting from our highly repetitous work is Carpal Tunnel Syndrome (CTS), the ever-growing hazard of the K&M athlete.

Granted Carpal Tunnel Syndrome (CTS) is treatable, the focus of this article is the *prevention* of CTS. Yes, "an ounce of prevention [truly] is..." As such, my hope is to increase the awareness of fellow computer users, offering them some basic information, some food for thought, and a way to encourage them to seek further information. The article is not intended to offer any definitive course of treatment to remedy or cure any health condition. With this in mind, let the games begin...

During the first week of 1997, I had a chat with Terry, a fellow E-Mail list bizwoman who had flown in from easy-going Florida to experience the Manhattan "scene." We were waiting on the Upper West Side for fellow women friends to gather at Edgar's Cafe. Bubbling with energy, youth and the excitement of being in the Big Apple, Terry was speed-schmoozing about the wonderful people she had met through the Net and the positive business and social experiences she had had as a result. I was sharing with her many of my own positive experiences online. We also agreed that most conventional media, is becoming increasingly "tabloid," focusing more and more on what they decide *for us* was "story" or "news" (mostly negative), which, for obvious reasons, they shamelessly consider "sexy."

Terry, an exec in a video production company, went on to describe the joys of her VP-dom. As the other women joined us, I mentioned how pleasantly surprised I was when, at Silicon Alley's first Webgrrls Expo (Oct '96), women were congratulating my Massage Therapy Web Central booth "just for being there." But I was even more amazed at how often an Expo visitor would catch a private moment to confide in me something like..."You know, I've been 'feeling' my wrist [or my forearm] lately.....Do you think it's.... serious? Perhaps Carpal Tunnel?" Terry's reaction was: "Really? I've never met anyone with Carpal Tunnel Syndrome..." She paused and then exclaimed, "Now wait, wait a minute! My own forearms have been bothering me lately too. Hmm... do you think it's 'it'? Do you think I should pay attention?" At this point, the other women who have joined our table were all looking (and listening) intently in my direction.

Most of us are familiar with the term CTS. Beyond that, however, the average person really knows very little about it--and is generally happy to know even less... But with what is certain to reach universal computer usage in the near future--with the likelihood of an even greater occurrence of CTS among the highly trained and well-educated white-collar segment of the population--it is not too early to broadcast the ever-expanding hazard of CTS. In fact the Science Section of the NY Times has already published "Epidemic at the Computer: Injuries Disable Workers and Cost Billions." Hopefully this article will help more K&Mers to stay tuned.

What, to be exact, is CTS? How do you "get it"? How do you treat it? Most important, I believe, is how do you *prevent* it? The medical profession knows what it is, and its earliest victims already know how it feels and how much it disables. But most K&Mers, especially the young ones (who already spend long hours uncritically immersed in their computer games), like young smokers and cigarettes, hardly believe that CTS relates in any significant way *to them*. For all practical purposes, they are completely "in the dark" about this growing K&M-hazard! The very first thing to learn--and keep in mind--about this disabling injury is that in its onset, CTS is subtle and insidious. The very next thing to learn about CTS, I repeat, is that it is PREVENTABLE.

In most K&Mers, CTS is the result of the improper positioning of the forearms, the incorrect use of the wrists and hands, and (therefore) the misuse of the fingers combined with the typical *work overload* involved in many, many hours spent daily at the computer without enough rest and without proper relief from stress overload. Just the growing popularity of E-mail has our fingers working overtime under real or self-imposed deadlines. And if we continue such work, mindlessly under adverse conditions, the consequences are certain to be dire.

In simplest medical terms, CTS affects the juncture between the wrist and hand, where there is a rigid bony passage--the carpal tunnel--through which pass the median nerve AND nine tendons. The median nerve is the major innervator of these tendons, which, in a bundle, control just about all the tensor (grasping) and extensor (stretching) movements of the fingers as well as the strength of the hand. As the carpal tunnel is relatively narrow (considering the heavy tendon "traffic" it bears), ANY swelling of ANY of those nine tendons must impinge upon that median nerve and, as a result of that swelling, interfere with its ability to innervate the fingers, too often the response to the continual sliding movement of those nine tendons against the wall of the tunnel--with ever-increasing pain and arrested movement.

Eventually CTS, which causes considerable pain and "congests" the neural pathways through the wrists, can seriously limit the use of the hands and fingers--if not in fact completely disabling them. It is particularly dangerous because its arrival is not only usually insidious and gradual but, far too often, mischaracterized (and therefore neglected) by its victims. The earliest symptoms are often misread--generally attributed to fatigue from overwork or a temporary strain, something like turning an ankle as the result of a casual misstep. The hands may "feel tired" or the wrists may "feel sore," with some "pins and needles" tingling or numbness, typically--and unfortunately--starting after work or even late at night. A too typical reaction: "What I need is a little rest, which I promise to get tonight," or "It'll just go away, somehow."

"To the contrary," says Joseph Bosco, MD, an orthopedic physician who specializes in reconstructive surgery and sportsmedicine: "Once a repetitive stress Injury occurs, the treatment period is usually long and arduous.

Ironically, MTs, who are in growing demand for the prevention and rehab of all sports injuries and repetitive stress injuries, are themselves prime candidates for CTS. Yet it seems that they have been more in denial about it... After all, they're expected to treat others, not themselves. Jane Brody confirms in her NY Times article what those who have been treating CTS well know: "People with these disorders, which can sometimes be permanent, can find themselves unemployable or forced to change careers. Favorite sports activities, housework, carrying groceries, or even holding a coffee cup may become difficult or impossibly painful."

For the longest time, by the way, it was generally accepted that women were more likely to suffer from CTS than men, with stats indicating from three to ten times the likelihood--Just recall how many women and few men were typists or MTs! More recently, however, as more men are becoming extreme keyboarders (K&Mers) and as more women engage in strength and fitness training, those stats are beginning to show less of a gender gap.

As we live in a society in which anything "extreme" is "cool," why bother with balance--with maintaining balance? Why? Because the concept of balance (and therefore of good health) is what all the healing arts--regardless of their varying philosophical underpinnings--have in common. When you consider to what lengths the bodymind complex goes to maintain balance within every system, every tissue, and every cell of the body and among those physical and psychological structures--24/7, balance is truly an awesome process. And it means that health too is not a static, given state but a never-ending agenda! How many of us forget that it is not "what" we do (or don't do) so mush as it is "how" we do it again and again? How many? Most of us, of course.

Have you considered how many of those "sexy" looking, highly fit--highly popularized--athletes develop some kind of repetitive strain injury before the end of their careers, injuries which, after retirement, often become chronic, limiting, and even disabling? None of us wants to hear about that, do we? Or take, for an opposite example, the pressure-generated bed-sores which bed-ridden people get as the result of, yes, excessive repetition of motionlessness. By putting repeated pressure on one poor median nerve and the surrounding tendons where they pass through the rigid carpal tunnel, by the disruption of balance between rest and motion, careless keyboard athletes declare a war of attrition on their own wrists.

Without the proper conditions for the maintenance of balance, the body's immediate survival-oriented defense mechanisms typically react with short-term "negative" adaptation, causing those tendons in the narrow carpal tunnel to become swollen and inflamed.

Much like any other athlete, ideally before getting hit by CTS--and definitely once cured of CTS, the fortunate K&Mer, must put into practice the "routines" that would have prevented CTS in the first place, routines that will minimize its recurrence in the future. Paying attention to any pain in the fingers, wrists or forearms is among the first MUSTS. "When I see a patient with suspected CTS, I routinely do motion testing of all the carpal bones to insure free range of motion," says Dr. Maria Kennedy, a Manhattan chiropractor. Dropping the idea of "No pain, no gain"--an idea with limited validity in a very limited context of body building--is particularly important for the maintenance of the balance and health of our upper extremities.

If we recall the most likely causes of CTS and its predisposing risk factors, we get our first clues to its prevention and the avoidance of its recurrence. To begin with, K&Mers must get into the habit of taking periodic breaks by pushing themselves away from the computer. During these breaks, the wrists should be slowly and gently rotated and the fingers stretched backward and laterally. Interweaving the fingers of both hands while tightening and releasing muscular tension helps greatly. Interlacing the fingers and then extending the hands overhead, palms upward, also affords relief from the rigors of channeled repetition. However, the best way to maintain optimum condition of the hands and fingers, to offset work-stress overload, to exercise nerve endings, to rid muscles of tension overload, to accelerate lymph flow and the removal of wastes, and to relieve pain *without* side-effects is--even for health professionlas--an hourly session of on the table of an MT professional.

While in training, MTs look at the body in isolation for the purpose of study and analysis only. In their practice, they may again do so, but only for the purpose of communicating with an attending physician or another health professional. In treatment, however, viewing the body as a complex of interdependent systems and structures--the psyche included, MTs routinely consider and treat other bodymind areas which are involved in most conditions and which MT, by its very holistic nature, touches upon so effectively anyway.

Thanks to the Internet, despite the proliferation of the commercial massage variety (in health-clubs, beauty salons, store-fronts, shopping malls, etc), K&Mers can now readily find an MT professional in the global directory @ MASSAGE THERAPY WEB CENTRAL. As for the would-be do-it-yourselfer, I must point out that self-massage is never as effective as professional MT simply because the therapy best occurs when the body is at rest and the mind is letting go Now that you know that MT work itself can lead to a case of CTS, you can easily see that self-massage can be...self-defeating.

If you who think that "Waiting to Exhale" is just the title of an engaging movie, you will be surprised at just how many people completely overlook the therapeutic function of "planned breathing," with emphasis always on good, thorough exhalation. For best results, the art of exhalation should be practiced on a regular basis for periods of two minutes as often as five to seven times a day with a minimum of once a day. Try and see for yourself how, upon full exhalation, many of your muscles relax, your pain threshold goes way up, and your energy is at its mostest (as when martial artists break thick boards or brickss, and more tennis players blast that ball).

If deep breathing alone sounds funny to you, believe me, it's not funny at all. Indeed, you might want to learn more about it by studying one of the Eastern exercise methods such as yoga or tai-chi, which make significent use of the healthful effects of our breath. Once the concept of deep breathing and thorough exhalation becomes respectable--in your mind--you'll be ready for an even deeper level of relaxation through regular meditation, body scanning, or self- hypnosis.

Any form of familiar exercise--always on a regular basis--is also beneficial: fast walking, jogging, dancing--ideally, activities which are not wrist-intensive. If you think that you don't have time (of course, you do), remember that even five minutes of daily exercise on a floor mat add up to many hours and days over a life time. A short daily routine should become a sine-qua-non for all--ha, ha, including MTs.

If I'm still having a hard time convincing you about the importance of moderate regular exercise in the avoidance of repetitive stress injury, would de-exercising be more appealing? I'm not kidding you. Stretching is an important form of de-exercising. It is an activity in which you take the time to bring a part of your body into a position which allows muscles to offset the flexion, tension, and depositing of waste involved in exercise, thus preparing your body for the workout to follow. (The term "de-exercising" grew out of my need to educate often obsessive runners about the purpose of stretching, which many of them mistakenly view as an additional exercise).

In places that are built on junk food, for over-all good health, a balanced diet can never be over-emphasized. Personally, the mere thought of well-off people suffering from malnutrition in the USA just blows me away...And I suspect that keyboard athletes are not un-informed about balanced diets. It's more, I think, a case of the lack of motivation, initiative, and exposure to just how palatable and well-flavored healthful food can be. Today, a click of the botton can take you to many sources of excellent food (or another click can take you away from junkfood sites).

In the "Computer User's Survival Guide," Joan Stigliani points out that "certain vitamins and minerals, such as vitamin B6, potassium, calcium, and magnesium may benefit muscles and nerves." In fact, according to Dr. Maria Kennedy, higher, though carefully monitored dosages of B6 are almost always indicated in the treatment of repetitive stress injuries. And don't forget that natural light is more than just "when I get around to it." Natural light has a direct nourishing affect on a variety of bodymind processes. Therefore, don't let your keyboard keep you away from natural light for days on end.

Just as we wonder if the USA will ever go metric or the UK will ever drive on the right, so must we wonder whether ergonomics, the science that promises to consider human factors and needs in the design of our work environment, will ever deliver. Things might be better if we were operating in a state of weightlessness, with our bodies assuming ideal attitudes in an ideal comfort zone. When asked about it, Emil Pascarelli, MD, who specializes in the treatment of repetitive stress injuries, reported: "We couldn't find a single mouse or trackball that we felt was safe to use for extended periods of time." Any questions?

My own experience as an especially high-risk K&Mer is the same as Pascarelli's. You see, in addition to years of MT practice and my extensive E-mailing, I also play conga-drums, the piano, and guitar...whew. These days I often wonder what will be the fate of that cute little Gintonomic keyboard (one-handed and user-friendly) that I designed in a graduate course on Human Factors in Engineering and Design in the late 70's, when the computer was still an exotic and foreign instrument to most mortals who didn't grow up in the burbs of Silicon Valley. Today, in fact, the K&M design of laptop computers seem to aggravate the situation. Utterly irresistible for transportation, they are otherwise "an ergonomic disaster zone." Aside from the keyboard and mouse, all other computer-related equipment should fit your size and needs. Your desk and chair should be relatively comfortable and must offer enough variation in height and reach. Ideally, I believe that K&Ms should be part of the chair, preferably a chair like the versatile, "flexible" electronic bucket-seat in my old Cadillac Cimarron. Until that happens, your money would be well spent on an adjustable K&M shelf which can be attached to your desk. A good fit of your desk and table is preferable to the use of a footrest. Use a footrest only if the height of your desk and chair do not allow you to rest your feet flat on the ground. Women, get rid of your high heels...

If you still use the phone frequently and for extended periods of time, don't save money. Get a comfortable, lightweight headset.

And even if you believe that your vision is 20/20, don't take it for granted. Enough computer work and your age will eventually change that. Ample indirect lighting in the room, adequate and readily available lighting on copyholders, steady light inside your monitor, comfortable eye-level positioning of the monitor, and an anti-glare screen will minimize eyestrain and slow down optical deterioration.

You wouldn't think that software has anything to do with ergonomics, that is, until you get a case of "software fruSTRESSion." Especially if you don't have a readily available geek who can stay cool and calm in the face of poorly written manuals, conflicts and bugs, and time-wasting tech support, don't blow your money on inexpensive software which you don't really need--and do plan for adequate installation, learning, and dealing with problems before you spend a lot of money on expensive software.

All of the above is common sense, isn't it? Can I caunt on you to help me make sense, well...common? Go ahead, talk to fellow K&Mers about preventing CTS and help spread the light to the end of the tunnel.

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