Hand Pain Discussion

The 4 Es of Injury Prevention

2009-02-04T09:59:00.000-08:00

When addressing injury prevention for computer users, four components need to be attended to in order to ensure success. Here are the four Es that will provide a well-rounded ergonomic program along with links to additional information.

Ergonomics – Ergonomics provides the optimal environment in which the body works. Ergonomics places the body in the most efficient and least stressful working positions. Without an appropriate ergonomic environment, the body will be at constant risk for injury.

Ergonomic ABCs

Monitor Position & Ergonomic Tips

Top Ten Ergonomic Picks

Exercise – Warming-up muscles prepares them for work. Warming-up increases blood and oxygen flow to the muscles and increases the muscle flexibility. Stretching ensures that the muscle is able to contract and work to its fullest efficiency without placing stress at the point that the muscle or tendon unit attaches to the bone.

Exercises for Preventing Hand Pain

Stretching for the Computer Athlete

Education – The work environment can be perfect but the equipment loses its effectiveness if it is not used appropriately. Training programs must be developed to support ergonomic programs.

Typing Style - Repetitive Injuries are NOT just about the Keyboard

Pain-Free Mousing

Monitor Position & Ergonomic Tips

Energy – Our body’s potential to produce work is a component of our fitness, health and well-being. Practicing general healthy habits will help our bodies heal from the everyday wear-and-tear and help prevent the micro-trauma that leads to repetitive injuries.

How to Develop Healthier Ergonomic Habits

The Effect of Smoking on Repetitive Strain Injuries

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.

Mouse Rest

2008-12-17T10:12:00.000-08:00

The wrist rest is probably the most widely used and misunderstood piece of ergonomic equipment available.

Placing a wrist rest in front of the keyboard has become synonymous with providing ergonomic adjustments to a work area.

When an ergonomic assessment is required, the very first item that is often checked off on the ergonomic modification checklist is provision of the wrist rest.
When clients tell me that they have made ergonomic changes to their computer desk, they often mean that they have purchased a wrist rest.

The Concept is Good, But….

My problem with the wrist rest is not with the concept. Wrist rests can play an important role in wrist positioning for those using a keyboard or mouse. The goal is to have a neutral wrist (the wrist being flat and straight, not bent forward or back or angled to either side). A neutral wrist angle reduces stress and friction on the structures at the wrist and can help reduce discomfort and fatigue with typing and mousing activities.

However, I do have two issues with the wrist rest. The first is in the name and the second is in the training (or lack of) for its use.

Purpose – Guide and Glide

In spite of the misleading name, the wrist rest is not designed for resting the wrist while typing. The wrist rest should guide the wrist into a neutral position enabling the wrist to glide over the wrist rest while typing. The wrist should only actually touch down on the wrist rest during typing breaks. If the wrists are actually planted down on the wrist rest during typing, the small finger muscles are isolated causing awkward finger positioning and movements and creating muscular stress.

Proper Wrist Rest Use

When typing, the wrists should be in a neutral position. They should float over the wrist rest and hand placement for key reach should be initiated through the shoulder and elbow.

See Neutral Position – Fingers, Wrist & Forearm

See Typing Style – Repetitive Strain Injuries are NOT Just About the Keyboard

Similarly, a wrist rest in front of a mouse causes the mouse to be activated by swiveling the wrist. This can lead to repetitive strain injuries and tendinitis. As with the keyboard, mouse movement should be initiated through small shoulder and elbow movements while the wrist is held in the neutral position.

See Pain-Free Mousing

The Bottom Line

Those who are responsible for providing ergonomic modifications to work stations should be aware of the proper function and use of the wrist rest. They need to provide the appropriate training if they issue a wrist rest. Otherwise, those who do not know better will revert to the function of this poorly named ergonomic piece of equipment and rest their wrists while typing - potentially increasing their work injury risk.

Female and Fashionable

2008-12-10T07:35:00.000-08:00

Women develop carpal tunnel syndrome, tendinitis and other repetitive strain injuries about twice as often as men. Hormonal shifts, fluid retention, pregnancy, and menopause are known to increase the incidence of risk for repetitive strain injuries. Also, women are typically smaller than men. Smaller bones and muscles need to work harder to perform the same job increasing the risk of muscular fatigue and strain. As women work with tools that are typically designed for larger bodies, they may be working on equipment that is too high or too heavy, causing the female body to work in awkward positions or perform forceful muscular exertions (two of the risk factors for developing a repetitive strain injury).

These are issues that we need to be aware of but may not be able to impact to a large degree. However, the following two tips for female fashion divas are things that we as women can do to immediately reduce our risk of injury from repetitive strain.

Long Fingernails

Women typically have longer fingernails than men. When fingernails are longer, typing style is affected. The least stressful position for typing is with the fingers relaxed and slightly rounded - as if the hand is resting over a large ball.

Typing should be performed by tapping the tip of the finger against the key using the least force necessary to activate the key. The longer the fingernail, the flatter the finger needs to be on the keyboard so that the pulp of the finger is hitting the key rather than the tip of the finger. This places stress on the smaller muscles of the hand that run between the bones of the finger. This also places stress on the muscles on the outside of the forearm.

If you are experiencing pain in the forearm or the outside of the elbow, try trimming those fingernails and type with the hand in as relaxed a position as possible using the tips of the finger rather than the pulp.

For more information:

Typing Style - Repetitive Injuries are NOT just about the Keyboard

High-Heeled Shoes

High-heeled shoes push the weight of the body forward. In order to maintain an upright posture, women use extra muscular effort, primarily in the lower back, to keep themselves from falling forward. This exaggerates the arch of the lower back.

In addition to possible back, knee and ankle pain, women who wear high-heeled shoes can develop shallow breathing patterns and tight neck and shoulder muscles from the extra effort that it takes to counteract the forward thrust caused by the shoes.

Lower the height of those high-heels if you are experiencing pain or change into flatter-heeled shoes throughout the day or if you are going to be on your feet for any length of time. If you do change between different sized heels during the day, take the time to adjust your office chair to compensate for the change in shoe heights.

For more information:

How to Develop Healthier Ergonomic Habits

Sources:

Repetitive Strain Injury; Stifling the Pain in a Pinch

mothernature.com

RSI on trial: More people suffering from repetitive strain injury are seeking compensation in court as fresh evidence comes to light about the symptoms and causes of this crippling disorder

Newscientist.com; 11 September 1993; John Ballard

Preventing Elbow Pain

2008-11-25T08:17:00.000-08:00

Traumatic injuries may be unavoidable. However, the risk of pain caused by stressful, forceful or repetitive activities can be controlled. Sportsinjuryclinic.net offers nine tips to reduce the risk of elbow injuries related to sports. I have modified these injury-prevention tips and applied them to the computer athlete or the desk jockey.

1. Warm-up before working. Warming-up increases the temperature of a muscle preparing it for work. It also increases the oxygen and blood flow to a muscle enabling it to work more efficiently with less risk of injury.

Use of Heat & Cold to Relieve Repetitive Strain Pain

2. Make sure you are using good technique. Sportsinjuryclinic.net provides tips for those playing sports. For the computer athlete or the desk jockey, this means looking at your ergonomic set-up and work methods. For example, avoid reaching forward for the mouse. Place it at keyboard height with your arm relaxed at your side and your elbow at a 90 degree or slightly greater angle. Keep the wrist neutral when using the mouse and manipulate the mouse through small elbow and shoulder movements rather than swiveling at the wrist.

Ergonomic ABCs

3. Make sure that you have the correct equipment. Again, in racket sports, this may mean having the correct racket size, grip size and string tension. For the computer athlete or desk jockey, ergonomic equipment and an appropriately fitted ergonomic chair can help prevent pain. Awkward positioning increases the stress on the body and makes the work that the body does less efficient, awkward and more prone to injury.

Top 10 Ergonomic Picks

4. Get a massage. Whether for the athlete or the computer athlete, massage can help relax the arm muscles and break down any scar tissue and trigger points. Massage along the length of the forearm muscles moving from the hand towards the elbow. Knead the bulk of the forearm muscle below the elbow joint. Plant two or three fingers from the opposite arm at the bony prominence of the elbow and perform small oscillating movements across the bone to improve blood supply to the location that the muscles insert on to the bone.

5. Strengthen. Strengthening the forearm, upper arm and shoulder muscles takes some of the strain away from the elbow joint.

6. Wear a brace around the muscles just below the elbow. This can help by taking some of the pressure off the attachments at the elbow and distributing stress throughout the arm. Sportsinjuryclinic.net explains the use and purpose of a clasp, support and sleeve.

7. Don't overtrain or suddenly change your training routine or daily activities. For the computer athlete or desk jockey, a change in routine, new desk set-up, or special project requiring long hours to complete can have an impact on pain level. If you notice an increase in arm fatigue or soreness, stretch often, use cold packs and take mini-breaks frequently.

8. Stretch. Stretching the muscles around the elbow keeps them flexible which helps to reduce the strain placed on the muscle attachments surrounding the joint.

9. Apply cold packs. For the early stages of elbow pain, whether caused by a sports-related injury or a repetitive or cumulative injury from the keyboard, cold can help reduce inflammation and help relieve muscle pain and spasm.

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.

Stretching for the Computer Athlete

2008-11-12T15:53:00.000-08:00

People often sit in poor or awkward postures while working on the computer, playing on gaming systems, using a laptop, and even manipulating hand held electronic devices. These postures can cause stress to the body. Over time, these body stressors may develop into repetitive strain injuries such as carpal tunnel syndrome or tendinitis.

Stretching and strengthening programs can be instrumental in easing the rounded shoulder and forward head postures that develop from computer or desk activities. A recent study shows that stretching may not only improve flexibility but can also enhance performance making people stronger and increasing their endurance (Chronic Static Stretching Improves Exercise Performance; October 2007; Medicine & Science in Sports & Exercise).

The study also suggests that stretching is an important part of an exercise program for those who are out of shape or just beginning an exercise program.

Here are a few recommended stretches for the computer athlete –
(Stretches should never hurt. Stop if you have pain. Hold the stretch gently. Do not bounce).

Stretch the Pecs

Face a corner with the forearms resting against adjoining walls, hands placed at about ear height. Put one foot in front of the other. Gently lunge forward (bending the knee of the leg in front) keeping the back straight. As the chest presses forward towards the corner, you should feel a stretch through the chest muscles. Hold for a count of thirty. Repeat three to five times.

(see picture at toneyourbones.com)
Squeeze the Shoulder Blades
Place your hands gently on the table in front of you. Leaving your hands on the table and keeping your shoulders relaxed, squeeze your shoulder blades together. Hold for a count of five. Repeat five times.
(see picture at toneyourbones.com)
Chin Tuck
Begin in a good, relaxed posture. Slide your chin back as if you are trying to give yourself a double-chin. Look straight ahead and do not tip your head up or down. Hold for five seconds. Repeat 5 times.
(see picture at silvafamilychiropractic.com, position 1)
Head Tilt (Scalenes Stretch)
Begin in a good, relaxed posture. Tilt the right ear to the right shoulder. Hold for ten seconds. Modify position by slightly rotating the head as if you are looking at the ceiling. Hold for ten seconds. Modify position again by slightly rotating as if you are looking down towards the floor. Hold for ten seconds. Bring the head back to the starting position. Repeat on the other side.
(see picture at silvafamilychiropractic.com, positions 2, 3 and 4)
Triceps Stretch
Place the right hand on the left shoulder. Place the left hand on the right elbow. Push the elbow towards your chin as if you are reaching for an object behind your left shoulder. Hold for 30 seconds. Repeat 3-5 times. Then repeat on the other side.
(see picture at adam.about.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.

Helpful Products

Several programs are available that can cue you to take a break when working on the computer. These programs also provide stretching instructions and illustrations.

Helpful Resources

ErgAerobics: Why does working @ my computer hurt so much?
Yoga for Computer Users: Healthy Necks, Shoulders, Wrists, and Hands in the Postmodern Age

Mouse Bridge

2008-11-03T11:45:00.000-08:00

A mouse bridge is a simple way of bringing the mouse in closer to your optimal work space while working at the computer. Typically, people tend to reach forward or out away from the body for the mouse. Because the keyboard tray may be too small to accommodate both the keyboard and the mouse, the mouse is often placed wherever space tends to be available, often to the far side of the keyboard or on a desk surface. Using a mouse bridge can make mousing activity more comfortable and less stressful on the body. Although the mouse bridge does cover the numerical keypad and prevents its use, the bridge can be easily moved for access to the keypad when necessary.

How Does A Mouse Bridge Work?

Ergonomically, the mouse converts the numerical keyboard pad into a mousing surface. This eliminates some of the awkward reaching or the awkward wrist angles that occur during mousing activity and that can contribute to repetitive strain injuries such as tendinitis and carpal tunnel syndrome.

What is a Mouse Bridge?

A mouse bridge is simply a thin piece of plastic or metal with shallow legs that fits over the numerical pad of the keyboard. Depending upon the type and shape of the keyboard, the style of this bridge may vary.

Who Needs to Use a Mouse Bridge?

Using a mouse bridge is the perfect ergonomic adaptation for those who have short keyboard trays that do not have a mouse tray attachment or for those who have limited desk space that places the mouse more than a half an arm’s reach away from the body during use. It is also helpful for those who have placed the keyboard and the mouse at different working levels.

When Will a Mouse Bridge Work the Best?

The mouse bridge is appropriate for right-handed mousers who spend a majority of time at the computer using a mouse but who do not use the numerical pad section of the keyboard. It can also be used by those who have distinct work tasks that use either the keyboard or the numerical pad at separate times.

What Styles are Available?

The Standard Mouse Bridge has legs that rest on the same surface as the keyboard (on the desk or the keyboard tray). It is larger as it fits around the keyboard and is good for those who have a standard style keyboard.
The Flat Mouse Bridge is the smallest bridge. It rests on the keyboard itself. It can be used with the Microsoft Natural Keyboard or with pull-out keyboard trays with limited space availability.
A Rear Mouse Bridge has legs that can be adjusted (raised) for extra clearance for higher keyboards or if the keyboard has a cable at the right rear.
A side mouse bridge is also available for use with the Microsoft Natural Keyboard.

A Few More Tips

When using an optical mouse, use a mouse bridge that is not transparent or place a mousing pad over the mouse bridge.
A mousing pad on the mouse bridge may also help improve mouse movement (tracking) if needed or may help prevent the mouse from sliding if the bridge is slightly slanted. Adjusting the legs on the mouse bridge or the slant of the keyboard tray can also help even the slope of the mousing surface.
If the mouse bridge slides, use a non-slip padding material beneath the legs.
If the mouse bridge is pressing on the keys of the keyboard, lower the legs of the keyboard so that it lies flatter. Or you may need to look into a different mouse bridge such as the rear.

ASHT News Bulletin Kids and Electronics

2008-10-21T15:26:00.000-07:00

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.

Pain-Free Mousing

2008-10-08T08:49:00.000-07:00

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.

Ergonomic ABCs

The Wrist and Repetitive Strain Injuries

DeQuervain’s Tenosynovitis – Repetitive Strain Thumb Pain

Samples of Products Mentioned in this Article

Rounded Shoulders

2008-10-03T06:51:00.000-07:00

When working at a desk or a computer, we often tend to lean forward, hunching over the desk, rounding our shoulders. Or we crane our heads forward to better view the monitor. Over time, these activities tend to round our shoulders, stretching the back muscles and tightening the chest muscles. This poor posture not only makes work more difficult to accomplish, placing stress on the upper back, shoulder and neck and leading to soreness, but it also can impact the effectiveness of our internal organs.

One way to check your posture is to have a friend stand at your side and observe the alignment of your ears in relationship to your shoulders. If your ears and shoulders are not in line, chances are your shoulders are rounded.

Another way to check your posture is to let your hands rest at your side. Normal posture would be for the thumbs to face forward, your palms facing towards your thighs. If the palms are facing towards the back, your chest muscles may be tight causing your shoulders to hunch forward.

Try this exercise to help your body ease into a more neutral posture.

Shoulder Circles

A good exercise is to roll your shoulders - move your shoulders forward, then up, then back, then down. Do this in a smooth, rolling motion several times. Emphasize the back and down motions.

For More Helpful Exercises

Check out this article at the Ergonomics Site at BellaOnline for additional stretches that will help you improve your posture and reduce your chances for developing work-related pain and strain.
Stretching for the Computer Athlete

Sleeping Tips

Sometimes a rounded shoulder problem can be made worse if you sleep on your side, curled up in a fetal position. You are rounding your back all night long. Instead, try learning to sleep flat on your back at least sometimes. It can be hard to learn a new sleep position - it feels very unnatural at first. However, give it a serious effort for at least two weeks.
Also, use a pillow that supports the neck but that does not push the shoulders or head forward such as the memory foam cervical pillow available at Amazon.com.

ASHT Guidlines for Hand Held Devices

2008-09-11T15:09:00.000-07:00

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

What Exactly is Carpal Tunnel Syndrome

2008-07-25T10:24:00.000-07:00

Carpal Tunnel Syndrome – Google the term and you will get over 600,000 hits. Pick up a magazine or newspaper and there is a chance that you will find some mention of carpal tunnel syndrome. Wear a brace or cast out in public and everyone will ask if you have carpal tunnel syndrome. The term has become a commonplace part of our language. There is even a band that goes by the name of Carpal Tunnel Syndrome.

However, the term carpal tunnel syndrome has become erroneously associated with all hand pain. The truth is that many other types of injuries can cause hand pain. In order to recover completely from repetitive strain pain, it is important to determine the true cause of the pain and not just treat the symptoms. It is important that we not assume and treat all hand pain as if it were carpal tunnel syndrome.

So, what exactly is carpal tunnel syndrome and how will you know if you have it?

Carpal tunnel syndrome is the compression of the median nerve at the wrist.

The nerves to the hands are long “threads” that start at the neck, branch under the arm pit, and travel down to the fingers. The nerves are the power cords that provide the muscles along their pathway with power and provide certain areas of the skin with sensation. They also assist with circulation and provide the skin with the ability to sweat.

The carpal bones are the eight small wrist bones that connect the hand to the forearm. They are arranged, for the most part, in two rows of four bones each. The arrangement of bones is slightly curved like a “C”. A strong, thick, wide ligament, the transverse carpal ligament, attaches from one end of the carpal bones to the other. The bones and the ligament over it create the carpal tunnel.

The median nerve passes through this tunnel on the way to the hand. Nine tendons also pass through the tunnel along with the nerve.

Tendons are the rope-like end of the muscles that attach muscle to bone. When the muscle contracts, the rope-like end of the muscle (the tendon) pulls on the bone and creates movement. The tendons that pass through the carpal tunnel are the eight tendons that bend each of the two finger joints plus the tendon that bends the thumb tip. These muscles begin at the inside edge of the elbow.

The nerve is the most vulnerable structure in the carpal tunnel. If there is any swelling of the tendons related to over-use, repetition, poor wrist positioning or any other cause, the nerve gets pinched and the nerve impulses do not travel along the nerve pathway properly. This can affect muscle power, sensation, and circulation.

The median nerve is responsible for sensation to the thumb, index, middle, and part of the ring finger. The median nerve is also responsible for the strength to the thick wad of muscles at the base of the thumb.

So the symptoms of a true carpal tunnel syndrome will be numbness or tingling in the thumb, index, middle and ring finger as well as loss of thumb strength and coordination. The fingers may be painful, the muscles at the base of the thumb may hurt, and sometimes people feel as if they have a tight band around their wrist. Pain may travel along the forearm muscles towards the elbow and the forearm muscles may become taut. People say that they often feel as if they are clumsy and they may report that they drop items frequently. They may also feel as if their fingers are slightly swollen. In advanced cases, the muscles at the base of the thumb may become wasted and flatten. Pain may radiate all the way up the arm into the shoulder and neck.

If you have these symptoms, a visit with a physician can help determine if carpal tunnel syndrome is truly the cause. Sometimes, if the same nerve is pinched higher along in the pathway, other causes can mimic carpal tunnel. Certain tests, along with your description of the symptoms, can help the doctor make a definitive diagnosis.

Check out these articles for additional information and for tips on preventing carpal tunnel syndrome.

Carpal Tunnel Syndrome - Back to the Basics

Carpal Tunnel Syndrome ABCs
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.

Emergency Preparedness

2008-07-09T11:29:00.000-07:00

The other night at sunset we stood in the local park and watched the flames of the Santa Barbara Gap Wildland Fire make their way down the slope of a nearby canyon. It was a truly awesome sight to see these tremendous bursts of flames as the sundowner winds fueled them on. And as we spent the night until the wee hours of the morning listening to the continuous news coverage announcing evacuations, I realized how ill-equipped the majority of us are for emergency situations. This theme of unpreparedness repeated itself as the news announcer took calls from listeners who were reporting their locations and situations. Many were frantically collecting their important papers and valuables or video-taping their home interiors to document for insurance purposes. Several had been given 30 minutes to collect items of importance and leave their homes. One woman reported “running around in circles” trying to get organized and get out in such a short amount of time. To complicate matters, many of us were experiencing wide-spread power outages caused by the ash and smoke short-circuiting the transformers. Although this is not an ergonomic issue, it can be a health and safety issue, which is related. And in lieu of all of the recent events attributed to global warming, I am going to deviate from our normal ergonomic channel and provide tips and information for preparing for a local emergency.
Have a plan. Know what to do and how to care for yourself and your family in the event that fire, police and emergency medical services may be delayed in responding.
• Choose a location to reunite the family if you are separated
• Choose a person outside of the immediate area who will act as the contact for all family members
• Locate shutoff valves for water, gas and electricity and know how to shut them off before an emergency.
• Make copies of vital records and keep them in a safe deposit box. Store the originals safely and have them gathered together in an accessible location in case of the need for a quick exit.
• Keep exits accessible and clear.
• Know the locations of the nearest police and fire departments.
• Take photos or videos of your valuables and keep a copy with a friend or relative in another city or state.
Keep a disaster kit ready at all times. Place the following items in easy to carry containers. This is a partial summary of the most important items.
• Food and water for at least three days
• Water and a water purification kit
• Non-perishable food – make sure you have a can opener as well
• First aid kit and manual
• Blankets or sleeping bags
• A portable radio, flashlights and spare batteries
• Essential medications
• Extra pair of eyeglasses
• Change of clothes
• Extra pair of house and car keys
• A fire extinguisher
• Food, water and restraint (carrier or leash) for pets
• Cash and change
• Large trash bags, tarps and rain ponchos
• Toilet paper
• Sturdy shoes and gloves
• Candles and matches and/or light sticks
• Knife or razor blades
• Tool kit including a wrench for turning off the gas, a screwdriver, pliers and hammer
• Rope
• Food preparation and consumption items (paper towels, plastic utensils, paper plates/cups)
If you have children:
• Make sure that contact and emergency medical information is current and correct.
• Be aware of the emergency plans of your school or day care center.
• Make plans for someone to pick up your children if you are unable to get to them.
• Have extra supplies for children including diapers, wipes, formula, pacifier, canned food and juices.
If you are elderly or have special medical needs:
• Have a current list of medications, allergies, special equipment needs, medical information and contacts including your doctor, pharmacist and family members.
• Have extra batteries in your emergency kit for hearing aids or other special needs equipment.
• Install a security light in each room.
• Keep pathways clear of clutter.
• Have walking aids near you at all times.
• Have a whistle near you to signal for help.
• Have a system in place to have two people you trust check in on you after an emergency. Give them a spare key and show them where your emergency supplies are including special equipment needs.
A special thank you to all of the firefighters and support personnel who are doing such a tremendous job keeping our city safe.
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.

Rotator Cuff

2008-06-23T09:09:00.000-07:00

Chances are, if you are experiencing shoulder pain, the rotator cuff is involved. The rotator cuff is composed of four muscles - the suprasinatus, the infraspinatus, the teres minor and the subscapularis - that provide a stable base for shoulder movement.

The stability of the shoulder is provided through these four muscles rather than by bony structure. These muscles are responsible for positioning and holding the head of the humerus (the long bone of the upper arm) into the shoulder joint. If the head of the humerus is not positioned correctly, it hits the overlying bone, the acromion, pinching the tendons and the bursa (a sack-like, fluid-filled cushion in the joint) causing pain and inflammation. When the head of the humerus is correctly positioned, the larger muscles that move and position the arm can work efficiently and properly.

Because the stability of the shoulder is provided by soft tissues such as the ligaments and muscles, the shoulder has great ability to position the arm and hand in a wide arc of motion for activity. However, the shoulder is also at greater risk for muscular sprains and strains than a joint that derives its stability from bone (such as the elbow).

Even though the muscles of a healthy shoulder work in well-balanced synergy, the muscles that rotate the shoulder inward (internal rotators) are naturally stronger than those that rotate the shoulder outward (external rotators). However, it is the external rotators that are essential for proper positioning of the humeral head into the shoulder joint.
When the muscles of the rotator cuff are in balance, shoulder movement is pain-free. When the muscles are out of balance, the risk for injury, pain and inflammation increases. The rounded shoulder posture that often develops from computer and desk work can lead to muscular imbalance. A large percentage of those who experience hand and elbow pain also have shoulder pain.

To prevent rotator cuff injuries, it is important to do the following:

Stretch the Internal Rotators
- Lie on your right side with your right arm at shoulder height, elbow bent 90 degrees. Using your other arm, gently rotate your shoulder inward bringing your hand towards the mat by your hip. Hold for 20 seconds. Repeat 2-3 times. Switch sides and stretch the left side.
- Picture of a Posterior Capsule Stretch from The Journal of the American Academy of Orthopaedic Surgeons
- Picture A – Use a pillow to support the neck in a neutral position and stretch the shoulder gently, not aggressively.
Stretch the Chest
- Standing by a door, rest your right forearm along the door frame with the elbow at shoulder height or slightly below. Keeping the forearm on the door frame, slowly turn your body away from your arm until you feel a gentle stretch across the chest and into the front of the shoulder. If you feel a pinch in the back, take a small step forward until you feel the stretch in the chest instead. Hold for 20 seconds. Repeat 2-3 times. Switch sides and stretch the left side.
- Picture of Doorway Stretch for the Chest (Pectoralis) from PhysioTherapyExercises.com
Strengthen the External Rotators
- Lie on your right side with your left elbow tucked into your side and bent at a 90 degree angle, hand towards the mat. Rotate your shoulder outward bringing the hand up towards the ceiling. Keep the elbow bent at the 90 degree angle and the elbow tucked in at the side. Hold at the end range for 3-5 seconds then relax the shoulder rotation and bring the hand back towards the mat. Repeat 8-12 times. Switch sides and strengthen the right side.
- Picture of External Rotator Strengthening Exercise from PhysioTherapyExercises.com
Focus on Posture
- Avoiding the rounded shoulder posture will help keep the head of the humerus in proper position.
- See these related articles for more information.
Follow Ergonomic Guidelines for Improving Positioning
- Being aware of correct ergonomic positioning while working at your desk or on your computer will help avoid the rounded shoulder posture.
- See these related articles for more information.

If you are experiencing shoulder pain that is interrupting sleep or work and leisure activity, it is important to seek medical consultation.

Information for this article was taken from The Seven Minute Rotator Cuff Solution: A Complete Program to Prevent and Rehabilitate Rotator Cuff Injuries by Joseph Horrigan, D.C. & Jerry Robinson.

Also available from Amazon.com

The Frozen Shoulder Workbook by Claire Davies & Treat Your Own Rotator Cuff by Jim Johnson, P.T.

Additional Products Helpful for Relieving Shoulder 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.

Epicondylitis

2008-06-04T16:11:00.000-07:00

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

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.

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.

Samples of Products Mentioned in this Article

Choosing & Adjusting an Ergonomic Chair

2008-05-28T11:17:00.000-07:00

The human body was not designed to keep still for long periods of time. And yet, the majority of American workers spend hours sitting in a chair while performing job activity. While sitting, the large muscles of the back, shoulders and neck contract to support the active movement of the arms and hands. This constant contraction can lead to fatigue and trigger points in the muscles. A good seating system can help alleviate this risk.

A good seating system allows for adjustability between body types. However, one size does not always fit all. A worker who is petite or larger may need to seek out special chair sizes that accommodate their body frames.

Here are some common adjustments that your office chair should be able to make.

1. Height - The chair should be able to be raised and lowered easily. Height is the first adjustment that should be made. When looking at the proper height of the chair, the elbows should be slightly higher than the work surface (desk or keyboard) so that the elbow is opened slightly greater than 90 degrees. The feet should be placed flat on the floor and the work surface adjusted (such as with an adjustable keyboard tray) if possible. However, if the work surface is not adjustable then the height of the work surface dictates the height of the chair. In this case, a footrest may be necessary to support the feet.

2. Depth of Seat Pan - The seat pan should slide forward and back to accommodate for differences in thigh length. If the seat pan is too shallow then body weight will not be distributed evenly through the thighs. If the seat pan is too deep or too narrow, you will be more likely to sit forward on the edge of the chair rather than taking advantage of the support of the chair back. The seat pan should also be rounded so that sharp edges do not press into the thighs and impede circulation. You should have a space of 2-3 fingers width between the edge of the chair and the back of the knee so that pressure is not placed on the nerves of the leg.

3. Back Support - The back of the chair should be able to be adjusted higher or lower to accommodate for a variety of heights. Proper lumbar support will help maintain the natural curves of the back and reduce the risk of back pain.

4. Seat Pan Tilt - Tilting the pan of the seat will allow you to accommodate for a variety of job tasks while still maintaining lumbar support. It will also allow you to vary working postures throughout the work day. Recent studies are now showing that a mild recline in a supported position is healthy for the back and reduces back pain. Slouching, however, reduces spinal disk height causing wear and tear on the lowest two spinal levels.

5. Arm Rests - The arm rests should raise and lower so that they support the forearms without causing the shoulders to be lifted towards the ears. A good chair will also have arm rests that can swivel or be pushed out of the way if needed. Arm rests should be broad and padded so that the forearm does not press into sharp edges.

6. Chair Base - Any rolling office chair should have a 5-point base of support for safety and stability.

A few more tips to help you remain pain-free while sitting at your desk or workstation -

* Visit an office supply store and take the time to sit in a variety of chairs to get the feel for one that is comfortable for you.

* Look for suppliers who have sample chairs that you can test for several weeks in the office environment.

* Learn to use the adjustments.

* Get up often and stretch frequently to increase circulation and reduce muscle fatigue.

Laptop Ergonomics

2008-05-15T08:49:00.000-07:00

Laptop computers and portable technology have changed the way we do business. With portable equipment, we are now able to work away from our primary office in a temporary or more comfortable location. We now have the luxury of working in a secondary or off-site office, while traveling, from the comfort of our home, and while lounging on the couch. However, in spite of their many benefits, portable computers, by their nature, increase the risk of developing repetitive strain injuries.

The keyboard and screen are attached in one unit. Because they are unable to be adjusted independently, an ergonomic compromise is created on positioning and comfort of either the neck or the arm.
Laptops are often used in cramped spaces compromising posture.
Laptop keys are smaller than traditional, desk-top keyboards causing the potential for increased hand and finger strain.
Laptop screens are typically smaller than standard causing potential eye strain.
It is harder to adjust the laptop screen to reduce glare.
Portable equipment is heavy to carry.

These shortfalls create the risk for pain, aching and muscular fatigue in the neck, shoulders, back, elbows, wrists and hands. They also create the potential for eye strain, headaches, numbness and tingling in the arms.

Putting these simple ergonomic adjustments into practice can help you reduce the risk of developing injuries while working on your laptop.

Stretch often.

Be aware of posture.

Take frequent breaks, every 20-30 minutes if possible.

Change your position often.

Switch the laptop position from the lap to the table every 30 minutes.

Putting the laptop in your lap will relax your shoulders.
Putting it on the table will relax the neck and reduce eyestrain.

Limit the peripherals you carry to the bare essentials to reduce the weight you carry.

Use a carrier with padded straps and frequently change the shoulder that the bag is carried on; or use a backpack with both straps over the shoulders to distribute the weight; better still, use a carrier with wheels.

Follow standard ergonomic positioning for a keyboard as closely as possible.

Keep the wrists neutral.
Keep the elbows open to 90 degrees or slightly greater.
The ears, shoulders and elbows should be in vertical alignment.
The shoulders should be relaxed. Do not round shoulders forward or hunch them up towards the ears.
The head and neck should be relaxed. Do not let head drop forward out of alignment with shoulders.

Use proper finger positioning, typing & mousing techniques.

Use two hands for 2-key functions.
Use the stronger fingers (modified hunt and peck) rather than stretching the fingers to reach for keys.
Keep the fingers relaxed.
Use a light touch while typing.
Movements should come from the larger shoulder muscles. Do not isolate the smaller wrist and hand muscles while typing by planting the wrists down.

Prevent eye-strain and headaches.

Frequently look away from the screen and look at an object far in the distance. Follow the 30-30-30 rule.
- rest the eyes for 30 seconds
- by looking 30 feet away
- for every 30 minutes of typing

Rub your hands briskly together until warmth is created and then place your warm palms over closed eyes. Hold the position for 20 seconds.
Frequently clean the screen using the appropriate antistatic cleaners.
Adjust font for color, contrast and size so that reading the screen is comfortable.

If you use the laptop as your primary computer, it is especially important to be aware of your positioning.

When you are in your office or primary work environment, elevate the laptop using monitor risers so that the screen in an optimal position and you do not need to bend your neck when looking at the screen; then, connect a separate keyboard and mouse at elbow level to position the arms appropriately.
When sitting in a chair without elbow supports or a couch, use pillows to support the arms whenever possible. Keep the same general ergonomic positioning guidelines in mind even if you are in a relaxed work environment.

The following exercises will help you stay flexible and keep you pain-free.

Stretch the thumb by gently pulling it back. Hold for 20 seconds.
Stretch the palm up. Hold for 20 seconds.
Perform basic forearm stretches.
- Place your hand out in front of you as if you are saying “stop” and pull the fingers gently back with the other hand. Hold for 20 seconds.
- Now let gravity drop the wrist down and gently increase the stretch by pulling with the other hand. Hold for 20 seconds.
Stretch the triceps and biceps stretches.
Perform shoulder and neck stretches.
Stretch the back.
- Gently interlace the fingers behind the neck and arch your upper back as if you are trying to look up at the ceiling (be careful not to pull the head forward). Hold for 20 seconds.
- Place your hands on your hips and arch the lower back as if you are trying to look up at the ceiling. Hold for 20 seconds.
Perform 15-20 minutes of daily cardio activity to improve circulation and oxygen flow to the arms for improved conditioning and better healing.
Perform core strengthening exercises to improve general postural stability.

Check out these samples of a laptop stand, ergonomic carrier and wheeled carrying case available from Amazon.com.

And a very cute laptop charm -

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.

Global Warming and Barometric Pressure

2008-05-06T17:56:00.000-07:00

The Center for American Progress has listed the Top 100 Effects of Global Warming. Global warming is being blamed for everything from killing the planet with glacial melting to threatening species of animals and negatively impacting our agricultural production. We are being warned that global warming will threaten our health with an increase in heat stroke, heart attacks, infectious diseases and smog/allergy related conditions. I would like to (jokingly) add an increase in carpal tunnel syndrome and other computer-related pain syndromes to the top 100 list of global warming effects.
Increases in severe weather are predicted as a response to global warming. Weather.com now offers a link to an aches and pains forecast that predicts how weather factors affect the way people feel. According to weather.com, the connection between weather and health dates back to Ancient Greece when the effect of hot and cold winds on pain and illness were described over 2,400 years ago.
Although recent studies are inconclusive, all of us know of that elderly relative who accurately predicts rain because of an aching knee or shoulder joint. Some people appear to be more weather sensitive than others. For most of us, the sensitivity to weather occurs as a result of the change in weather rather than from any specific weather condition. Personally, I know that barometric pressure changes will bring more reports of pain on any given day in the therapy clinic.
Barometric pressure is the measurement of the weight of air molecules around us. When the weather changes the weight of the air molecules change. A rapid fall in pressure signals the onset of stormy weather. This change is highly correlated with an increase in body aches and pains. As the barometric pressure drops, the gas and tissue around injured or inflamed joints can increase resulting in more pain.
So, if you are prone to computer-related pain, plan to weather the storm by taking extra precautions during the time of barometric pressure changes. Be particularly aware of your posture, positioning and work methods; take frequent breaks; stretch often; and use you choice of over-the-counter anti-inflammatory medications as needed. Heat or cold packs can also be helpful.
And it certainly won’t hurt to live green.
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.

Related Articles

The Top 100 Effects of Global Warming

Weather.Com Aches and Pains 101

Cleaning Green – BellaOnline.com

Ways to Celebrate Earth Day – BellaOnline.com

Gaming Ergonomics

2008-04-22T08:30:00.000-07:00

Away from the formal constraints of the work environment, we may find ourselves relaxing at home in front of the computer or television or on the couch in positions that are not necessarily healthy for our bodies. Does anyone run through the checklist of proper ergonomic positioning and practices prior to beginning a leisure activity? It just doesn’t seem right that activities we enjoy should increase our risk of developing carpal tunnel syndrome (CTS) or a tendonitis. But, as many gaming enthusiasts have discovered, repetitive strain injuries (RSIs) do not occur only during work hours.

The gaming industry is currently in a period of explosive growth. According to a Global Entertainment and Media Outlook 2004 – 2008 study by PricewaterhouseCoopers, the video game business was accurately projected to outsell both the movie and the music industries by 2006. A compound growth rate of 20% annually projects 55 billion USD in video game revenue by the end of 2008. It is estimated that 50% of the population plays video games

Gamers are at increased risk of developing RSIs. Games are most often enjoyed after work or school activity when muscles may already be fatigued or when tendons and nerves may already be stressed or inflamed. The gaming environment may be spontaneously chosen and is not likely to be set up for ergonomic comfort. Players may unwittingly end-up in awkward and unhealthy positions (for example, lying on the stomach with the neck craned up to see the television screen). The practice of playing is repetitive. Achieving game tasks and goals may promote nervous and muscular tension. The controllers may cause mechanical pressures with sustained holding and with additional features such as force feedback (for example, vibrating to enhance the game in relation to the activity on the playing screen). And pain signals may be ignored because the enjoyment of the game overshadows them.

In 1978, Space Invaders was released, and it became the first game to receive the distinction of having a medical condition named after it – Space Invader’s Wrist, a tendonitis caused by wrist and forearm movements required to maneuver the spaceship. Pac Man’s Elbow followed closely behind along with Slot Machine Tendinitis. In 1989, Gameboy introduced a whole new era in gaming with handheld gaming. Currently popular maladies are Nintendinitis, Nintendo Thumb, Atari Thumb and Blackberry Thumb. Although the names of these repetitive strain injuries do not necessarily invoke the seriousness of the condition, symptoms can be quite debilitating and range from pain and aching to tingling, numbness, and muscle spasms and cramps. Symptoms can be severe enough to cause a loss of function in self-care, leisure and work activities. Many gaming guides, such as Microsoft’s X-Box Healthy Gaming Guide, now offer information and suggestions on avoiding gaming pain.

Here are some ergonomic tips for remaining pain-free while playing the game:

First and foremost, if you are having pain while playing, you need to rest from the activity.

If painful, use cold packs for 10-15 minutes after play to control inflammation and spasms.

Take 10-15 minute breaks for every hour of play.

Stretch often.

Perform 15-20 minutes of cardio activity daily to improve circulation and increase oxygen flow to the arms.

Use pillows to support the arms when playing.

Use the lightest touch possible when activating the controller.

Try to keep the arms relaxed and the controller positioned close to your lap rather than having your arms fly up towards your chest.

Try to alternate more intense games or play sequences with those that are less intense.

The room should have adequate lighting. There should be no glare on the screen.

Prevent eye strain by following the 20-20-20 rule. For every 20 minutes of play, focus for 20 seconds on an object 20 feet away.

When setting up to play, be aware of your positioning and environment.

If playing on a PC, check out Ergonomic ABCs for computer ergonomic tips. The same principles apply when setting up for leisure activities as well as work activities. If not sitting formally in a chair, use pillows and lapboards to help achieve neutral positioning.

If playing on a smaller handheld device such as a Blackberry or SmartPhone, check out SmartPhone & PDA Ergonomics.

If playing on a console game system using the television as your screen, avoid twisting or crimping the neck by positioning the couch or chair so that the screen is at eye-level and directly in front of you. Support your arms with pillows. Have good back support. Turn off the vibration feedback from the controller or limit the time it is used. Use pillows and lapboards to help achieve neutral positioning.

Special Considerations for Children

The content of games should be appropriate for the child’s age.

The controllers or keyboard should be appropriately sized for the child’s developmental age – small enough to fit comfortable in petite hands but with buttons large to be manipulated by those who are less coordinated.

Check out ergonomic tips specifically for children at Kids & Computers - Ergonomic Guidelines

Encourage physical activity daily.

Promote healthy habits.

If you are experiencing pain, these are the best cold packs on the market. We use them all the time in the clinic. They are durable, do not leak, will not puncture, are comfortable, and conform well to bony areas. The Velcro strap is a nice addition to hold them in place when you are on the move.

Using a lap desk can help position your arms comfortable while gaming on the couch.

Common Sense Repetition 1

2008-04-14T13:49:00.000-07:00

Patient: Doctor, it hurts when I do (….insert work, home, or leisure task…). Doctor: Well, don’t do that.
I’ve had many clients who are frustrated, having heard this, knowing that they cannot stop working or performing the activity that is painful. Although it is helpful to work with an ergonomic specialist who can show you specific ways in which to make your work less stressful on the body, a common-sense approach to activities can also make a difference.
This multi-part series will offer some common-sense tips - based on the ergonomic principles of avoiding repetition, force and awkward postures - that can help you avoid pain while working.
REPETITION
I worked recently with a graphic designer who was having pain in both arms. Working long days to complete a complicated project, a mouse-click counter showed that he was clicking the mouse between 10,000 to 15,000 times per day. The graphic designer researched available software and was able to purchase a new program that reduced his mouse clicks to 3000 to 4000 clicks per day. By the time he attended his first appointment with me, this client was already well on his way to recovery because he had intuitively related his pain to mouse use, confirmed this with the mouse-click counter, and taken steps to reduce the repetition by researching alternative software packages and changing to a program that demanded many fewer clicks.
Methods of Reducing Repetition

Look for ways to break up the repetitive components of a job. For example, after an hour of so of typing, make a few phone calls, walk down the hall to consult with a co-worker (rather than e-mailing), stretch or get a drink of water.

If your job requires a variety of duties, switch frequently between tasks rather than completing each one before moving on.

Do some research and find a different tool that makes the job easier (such as the different graphic design program in the example above).

Let the tool do the work instead of the body. Use power tools (for example, an electric screwdriver or tools with special ratchet devices) or automation when possible.

During the work week, be open to discovering leisure activities that have different physical demands than work activities. Enjoy leisure activities with similar physical demands on the days that you do not work.

Definitions
Job Enlargement is the process by which a worker is provided with a greater number of tasks to perform so that repetition of any one particular movement in reduced.

Job Rotation is the process by which employees are rotated through different jobs. This works well when the demands of the job itself can not be changed (for example, assembly line work). The key is to rotate employees every few hours between jobs that require different physical demands.

Next Week – Methods for Reducing Force & Awkward Postures
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.

Typing Styles

2008-04-09T10:29:00.000-07:00

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.

Ergonomic Process - When it Goes Bad

2008-03-12T14:19:00.000-07:00

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.

What is Writer's Cramp?

2008-03-05T11:03:00.000-08:00

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.

Wii-itis

2008-02-17T16:23:00.000-08:00

In the 1990’s, carpal tunnel syndrome was occurring in epidemic numbers. As a result, it is now fairly easy to find a book or magazine, or visit a website, that provides information on preventing repetitive computer-related injuries.
However, as technology is rapidly changing, so too is the type of injuries that people experience. Larger computers are being replaced with hand-held gadgets, and these gadgets have their own set of injuries associated with them. In addition, children and adults alike are spending large amounts of time playing simulated sports and musical (for example, Guitar Hero) activities requiring movements that their bodies are not accustomed to. Because of the enjoyment of these activities, the body’s warning signals may be ignored. The December issue of Women’s Health Magazine listed some of the newer injuries and provided a few prevention tips. Here is a summary.

Wii-itis – Simulating sports or leisure activities, such as bowling, tennis, or playing the guitar, can result in actual injuries if performed for excessive amounts of time. Prevention Tips - Moderate the time you play. If you must play for longer periods of time, take a 10 minute break for every hour of play. Stretch the muscles that are being used often.
BlackBerry Thumb – Holding a stylus for long periods of time or repetitively reaching for those small PDA keys can cause thumb cramping and pain. Prevention Tips - Limit your text messaging, take frequent breaks stretching all the fingers as widely as you can, and use an ice pack for 15-20 minutes once a day if you begin to have thumb pain.
Cell Phone Elbow – Keeping the elbow bent for long periods of time while holding the phone to the ear can reduce blood and oxygen supply to the ulnar nerve at the elbow causing pain, weakness and numbness in the small finger. Prevention Tips– Change the hand that is holding the phone every 5 minutes. Avoid leaning on the elbow as this can place extra pressure on the nerve.

For More Information -
PDA & SmartPhone Ergonomics
PC & Video Gaming - Ergonomic Tips
Cubital Tunnel Syndrome - Carpal Tunnel's Counterpart

Hand Health Resources Newsletter

2008-01-16T10:18:00.000-08:00

Sign Up for the Hand Health Resources newsletter. Full of tips, ergonomic suggestions, exercise descriptions and fun facts about hands and how to keep them healthy.

For Email Marketing you can trust

The Benefits of Pain

2008-01-14T13:08:00.000-08:00

The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. The word "pain" comes from the Latin root poena meaning punishment, a fine, a penalty (Wikipedia: Pain and Nociception). Although often associated with negative feelings, pain actually has some very important functions.There are two types of pain: acute pain and chronic pain. Acute pain occurs for specific reasons. With acute pain, an actual or potentially damaging event triggers special sensory nerve endings located in the skin, muscles and joints. These neural impulses then travel through the dorsal horns of the spinal cord and up to the higher centers of the brainstem and brain. An automatic and rapid course of action to eliminate the event and prevent further injury is decided upon.

Acute pain is a protective mechanism that helps us avoid damaging situations. It warns us that damage is imminent and provides information that the body uses to avoid further injury. For example, acute pain warns us to quickly remove our hand from a hot stove top.

Acute pain lets us know when we need to seek medical attention - such as when we have received a cut, broken a bone, or are having a heart attack. Our action may be as small putting on a band-aid or as extreme as a visit to the Emergency Room.

Acute pain is also a signal that we need to rest a body part to allow it to heal. For example, the pain of a broken ankle prevents us from putting weight on the leg until the bone has healed enough to withstand it.

Many RSI (Repetitive Strain Injury) sufferers experience chronic pain. Unlike acute pain, chronic pain serves no purpose. It is defined as "the disease of pain" (Wikipedia: Pain and Nociception). The initial purpose of pain is long forgotten but the pain continues and may even worsen. A stronger emotional component is associated with chronic pain including anxiety, depression and helplessness.

The benefits of acute pain are automatic body responses that prevent the body from further injury. We can some receive some of the same benefits with chronic pain; however, our actions will need to be more deliberate and thoughtful rather than the immediate and spontaneous requests demanded by our body.

Pain as a Warning Signal

Reduce environmental stresses on the body by making appropriate ergonomic changes to the work area.

Use the body smarter, not harder. Use proper body mechanics when performing tasks such as lifting, carrying, pushing and pulling. Use power tools. Pace yourself. Use the strongest and largest muscles to perform heavier jobs. Plan ahead. Use good posture.

Change harmful and painful work habits. Don't ignore pain. Stretch regularly and take frequent mini-breaks. Avoid static grip or positioning. Avoid awkward positioning.

Pain as the Body's Request for Healing

Seek medical attention. Be specific with your pain concerns so that your medical practitioners can better diagnose your injury.

Think outside the box with alternative treatments such as: Yoga, Pilates, movement therapies such as the Alexander Technique and the Feldenkrais Method, massage therapy, acupuncture.

Develop healthy habits: consult with a nutritionist, stop smoking, get a good night's rest, perform 15-20 minutes of gentle cardio activity daily.

Pain as a Signal to Rest

Take frequent mini breaks. If you are less painful by the end of the day, you will actually be more productive for taking these breaks than if you worked straight through.

Use splints and supports to rest painful joints and muscles. Your physician or therapist can help you choose the style that is most appropriate for your condition and provide instructions for wearing time.

Use cold packs to control inflammation.

Use either heat packs or cold packs to alleviate pain. Both may help to reduce pain by changing the way the pain signal is delivered to the brain. Try both and choose the one that feels the best.

For further information on injury prevention and recovery, visit Hand Health Resources.

Using cold packs can help reduce inflammation and alleviate pain. Elastogel cold packs are well made, durable, don't leak, feel nice against the skin, and fit/conform to body areas comfortably. This is my choice of cold pack in the clinic. An added bonus is that they can also be used as heat packs. The velcro strapping is a nice addition to hold the packs in place.

Elasto-Gel Hot/Cold Wrist or Elbow Wrap - #WR200 Elastogel

There are many topical pain relieving gels and creams on the market now. Biofreeze is one of the preferred choices by my clients in the clinic. It is easy to apply and does not leave a long-lasting, strong odor.

BIOFREEZE with ILEX Pain Relieving Gel - 4 oz. Tube

This book introduces trigger point therapy as a self-care tool for alleviating chronic pain caused by a variety of conditions. It has nice illustrations and consistently gets good reviews.

The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief, Second Edition