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Ask HN: Avoiding carpal tunnel / repetitive stress injuries
14 points by wensing on June 23, 2008 | hide | past | web | favorite | 43 comments
I'm 26 and have been hitting keys since I was 6 or 7. For the first time in 20 years I now have a burning pain in my right hand and wrist. I think it has a lot to do with my mouse. I've switched to an ergonomic keyboard, and have also begun using a keyboard tray, placing it low enough so that my shoulders are relaxed when I work. But the pain persists. MacSpeech Dictate has pretty sweet accuracy and can replace typing for IM conversations and email, but I still have to type to code.

What are any of you doing to prevent such injuries? Do you think about the possibility? I have a feeling it could end up being something of an 'unexpected' pandemic (three co-workers of similar age have also begun to see their first symptoms).




Get religion about ergonomics. I've spend close to $1k on my workstation's ergonomics at home (decent desk, chair, keyboard, tried a bunch of different mice, adjustible monitor arms, etc...) I probably need to invest another $500-1000 just to get it tuned even further. A small price to pay, to not have to quit coding.

Is the pain in your R hand on your wrist (palmar side?) or is it in the back of your hand? It' makes a difference. A doctor can help you sort things out. All the tendons and nerves that control your hand flow through a narrow band in your wrist. If you rest your arm's weight on your wrist for extended periods of time (i.e. mousing on your R hand), you can put pressure on that bundle of nerves and tendons. Do it too long, and you can end up like a friend did and not be able to button a shirt for 4 months.

So, may I suggest a trackball, trackpad or vertical mouse. I actually have a track ball and a mouse connected to my computer, and I switch back and forth between them every so often. I'm probably going to purchase a vertical mouse soon, because my wrist is aching a little bit.


before spending $1000, adjust your chair, keyboard, and mouse so that your posture is good, your shoulders are relaxed and your wrists are in a neutral position. You may not be able to do this with a standard keyboard, but a split keyboard is less than $100. if your chair doesn't adjust, get one that does. I personally like a chair that doesn't have armrests, as they sometimes cause me to raise my shoulders or contort my wrists, and I am comfortable resting my arms on my body/legs/


Thank you for the questions. I realize now that I have been resting my wrist on the chair armrest in an attempt to keep my wrist and arm and hand straighter (thinking this was healthier). But now I realize that even if that whole unit is straight, the resting itself is damaging. Thanks.


1) Get a mouse that's flexible enough to use with either your left or right hand. It might feel weird at first, but switching sides every hour will reduce a lot the pain. Takes a bit to get used to but you'll eventually adjust.

2) Try to use the keyboard as much as possible for everything. Go into your Keyboard & Mouse settings and enable full keyboard access (or ^fn F7 to toggle on/off)

3) Use either Firefox/Camino for you main browsing because you can enable "find as you type" which you can use to navigate the links on a web page.

4) Take regular/breaks. I use http://tech.inhelsinki.nl/antirsi/ to remind me at set intervals.

5) Exercise regularly (running, walking, golf, something to get you away from you computer).

6) Meditate, relax, listen to music. Whenever I feel like I'm tired or overstressed, I listen to this for about 20 minutes. I'll feel refreshed and much more focused. http://www.pzizz.com/ (Energizer track)


I just went to a physiotherapist about this very issue, here's what I was told.

First, I've been experiencing a dull pain shooting up the BACKS of my hands to my wrists, following the middle finger. This may or may not be what you have, and I recommend looking into this yourself. It cost me 80 CAD to visit a physiotherapist and it was worth every penny. If you are going to be typing for the next 5, 10 years or longer (here's hoping we get a better input system...) I urge you to visit at the first bit of pain.

Onto the diagnoses. A primer on the human body: the nerves and blood vessels that get to your hands come from your spinal cord. To get there they must pass under the collarbone and above the first rib. My problem is that I have a slight posture problem (no one has ever noticed it) where my shoulders slouch forward a bit. This is very common for people that use the computer a lot, and it was compounded by my height (6'3''). As I am a tall person, I slouch while talking to people, inspecting things, pretty much whenever I do anything in a world built for the average sized guy.

This posture problem results in a small constricting of the space between the collarbone and the first rib - putting pressure on the blood vessels and nerves going through there. This causes extra strain whenever you pull on these items (which you do while moving the fingers). To make matters worse I do not do a lot of upper body exercise. I run 3k a day and bike about an hour and a half, but none of these tasks work my back muscles. While typing for extended periods of time these muscles recognize they are not needed and 'shut off' to conserve energy. If they were used more they would not be shut off as quick. When they are shut off the shoulders slouch more.

I was recommended a series of stretches to help the constricting of the blood vessels and nerves. I was also recommended to start swimming regularly to build muscle. I have also started using the program "instant boss" (quick and dirty program) to have a 10 and 2 schedule - 10 minutes on and 2 off. I follow it religiously.

I'd define the stretches but my hands are hurting a bit and I need to stop typing. I do recommend seeing a physiotherapist yourself though to get customized stretches that fit your body type. Take breaks, really read up on ergonomics.

Hope this helps.


See a medical professional! That said, anecdotal not-medical-advice:

I had mousing-related pain, and I fixed it by mousing left handed. The first couple of days were incredibly frustrating, but after a week I had probably 80% of my right handed dexterity.

To prevent the same issue from building up in my left hand, I started alternating between left handed and right handed mousing every couple of weeks.

I guess the worst case outcome here is severe damage to both hands, so proceed with caution.


Exercise.

You will probably ignore that, so let me say it differently.

Every day, at least 15 minutes, cycle, run, I don't care. Move.

Every week at least once, do something (I like Climbing) that gets your whole body, but especially your ARMS dead tired.

You don't need any kind of special keyboard layout, just something with good key response. It is far more important what you are doing with your body when you aren't sitting.


Exact same age and symptoms as me - 3M ergonomic mouse fixed it right up. http://www.google.com/url?sa=t&ct=res&cd=3&url=h...

Also using my left hand for touchpads and wearing a brace helped get through the worst of it.


Seconded. I was doing 3D work, which involves a lot of mousing. The 3M joystick-style mouse greatly increased the amount of time I could comfortably work. The middle mouse button gummed up on me after about two years... I couldn't figure out how to clean it out, so I just replaced it with the same model.

I also recommend learning the keyboard shortcuts for whatever environment you work in, to minimize switching between mouse and keyboard. If you find yourself doing a lot of text cursor movement with the arrow keys or mouse, you might want to try vim for a month or two. (I tried emacs, but found it ergonomically uncomfortable, although I did not remap the keys from their default positions, which I understand other people do. I have not heard any statistics on the matter, but it would not surprise me to learn that emacs users are more prone to RSI than vim users.)

Try to work in an environment that is not too cold (or wear fingerless gloves). I found the cold made my joints uncomfortable and was bad for circulation.

Also, install Workrave (or equivalent for your platform) in the most obnoxious configuration you can stand. Even though my wrists are pretty good now, I still keep it on in quiet mode in the corner of my screen, to help me keep track of my breaks.


For me, I was starting to get wrist pain with my mousing. I purchased 12 different mice, tried them all out, keeping note of how I felt in my hand. I eventually found out that really large mice is what work for me. The M$ intellimouse explorer specifically. The MX revolution, and all the other fancy mice weren't as good as the huge honking intellimouse explorer. The huge thumball mice were also good, but I didn't have the patience to learn them.


This is really interesting, because right now I use a very small wireless travel mouse.

Actually, I've ditched it and have begun mousing with my feet: http://www.bilila.com/foot_mouse_slipper_mouse

From 2000-2006 I used the MS Intellimouse. I should have stuck with it. Perhaps now if I must use a traditional mouse again I'll purchase another. Great tip.


small mice always cause me problems


Good thread from 6 months ago:

http://news.ycombinator.com/item?id=104977

Some of the tips given there took my pain away.

In particular, the Microsoft Ergonomic Keyboards with negative key pitch are awesome, as are ergonomic mouse pads.


There was a thread a few years back on comp.lang.lisp about this very topic.

Peter Seibel (of 'Practical Common Lisp' fame) replied:

"Okay, here's how I do it. Of course I tend to overdo things--how do you think I dorked up my wrists in the first place so I can't say this is necessarily recommended practice:

a. Fill one pitcher with cold water and a tray or two of ice cubes, leaving room for you to immerse you hand and wrist without overflowing.

b. Fill another pitcher with scalding hot water, again leaving room for as much of your hand and wrist will fit into pitcher without bending your wrist at some weird angle.

c. Stick affected hand in ice water. Scream in agony until the numbing takes the edge off. Leave in for 1-4 minutes.

d. Move affected hand to hot water. If you timed it just right the water has cooled just enough that you avoid parboiling your hand. Leave in for 1 minute. Move your fingers around some.

e. Go to c until you get bored or the water in both pitchers has gone tepid.

I also periodically freshen up the hot water by filling a mug from the hot-water pitcher and microwaving it for a minute while I'm soaking in the cold water and then putting it back in the hot pitcher when I'm ready to switch. But I'm pretty weird.

-Peter"

Or you could just get a reasonable keyboard. I've been lusting after a Kinesis Contour for some time now ...


My solution was to place a standard building sized block of wood measured to the length of my standard keyboard under the keyboard so the nearest edge of the keyboard sits up on the block, and the furthest edge of the keyboard sits on the table as usual. This way, the wrists can rest on the flat upside section of the wood with the fingers then drooping over onto the angulated keyboard. It's meant to simulate how your arms and wrists feel when you hang them down freely - no flexion of the wrists up or down, and relaxed.

Similarly, place a thick book near your mouse for your wrist to wrest upon, leaving your palm to drop onto the mouse which slides on the pad that sits on table. For me, smaller mice are better that can be moved with just the fingers and highly sensitized.

This solved the RSI in my forearms.

Note: The wood block must be the correct size so that the keyboard slants neither too high nor too low, and that the forearms do not touch.

I use: '2x4 (pronounced "two by four"), but few people realize that the actual height and width of a 2x4 is really somewhere close to 1 1/2" x 3 1/2"' http://woodworking.about.com/od/typesofwood/p/WoodSizing.htm


The following three things helped me tremendously.

(1) Stop using an external mouse. Right now. The sideways flick your wrist does when you reach for it is murderous. Most laptops' integrated pointing devices will help a lot. The Apple trackpad is great. IBM (Lenovo) trackpoints work well too. Switch up hands you use for the pointing device.

I lucked out on this one: the last desktop computer I ever owned died just as my RSI symptoms peaked. I then didn't regularly use a computer for around three months, which let the symptoms subside. I've owned a laptop as a primary machine ever since (eight years now), and have had very few recurring symptoms.

(2) Exercise. This is huge topic, obviously, but in particular, core strength development will help your body in surprising ways. Very specifically, use light (<20 lb or <10 kg) dumbbells and do regular and reverse wrist curls. Obviously go easy on these at first.

(3) Keep your wrists straight when you type. Easier said than done, of course, but good posture and a good chair will help out here.


Things I've done:

  -switched the mouse to my left hand 
  -installed WorkRave, actually did what it said
  -switched the caps-lock and ctrl key
  -switched to dvorak
  -use the ergo microsoft keyboard
  -avoid laptops
  -learned to sit up straight and not cross my legs
  -stopped using the mouse scroll wheel
These days I'm trying to pay attention to my keystrokes. For example, using the right shift to make (){} results in some stressful twisting, so I'm trying to cut that out.

If you spend a lot of time coding, try to spend more time with a pencil and paper designing before you hit the keyboard. That gives you a good break and reduces the amount of typing and deleting you'll do.


By the way, sitting up straight is actually worse for your back than leaning back comfortably. http://news.ycombinator.com/item?id=185187


Dang.

You're right though, this is much more comfortable :)


1. Ergonomoc evaluation by a specialist to set up your desk, monitor etc. Ask your employer, they should provide it.

2. Inquire about work-place injury laws in your state. Your employer will likely have to pay the expenses.

3. Record all expenses no matter who pays for them. If you become disabled reciepts may help to make employer shoulder part of the weight.

4. Physical therapy. It's important to continue excersizing until, well, forever.

5. If mouse is source of your problems try using two mouses alternating left and right hands. You'll get used to it.

6. Carpal tunnel and RSI are two very different things. It's important to see specialist to tell one form the other. Carpal tunnel is actually quite rare, but consequences are severe.


Things that have worked for me:

-Stop using a mouse. Use a trackball or a trackpad or anything else. I have a death grip on mice and I bet others do too.

-If you have to use a mouse switch your mousing hand. Deal with the fumbling and inaccuracy. You'll figure it out.

-Lean farr back in your chair(legs propped up) and rest your keyboard in your lap. Shift position occasionally.

-Move your monitor so that you look in different directions. Laptops are great for this and that compensates for their other ergonomic problems. You can usually find a way to move them higher or lower and correspondingly shift the strain.


Dvorak solved this for me permanently.


How did Dvorak solve this for you? And, how was it permanent?


The difference between Dvorak and Qwerty, in a nutshell, is that Dvorak was designed scientifically while Qwerty was designed in a mostly arbitrary way to avoid jamming in the early designs of typewriters.

Dvorak optimizes alternating hands (ever felt dumb typing "street" or "states" in Qwerty?), useful keys on the home row (aoeuidhtns VS asdfghjkl;), typing inwards (try tapping your fingers in rapid succession inwards on your desk. Now try outwards or in a random order...) and typing with the strong fingers (The farther from the pinky the better) and the right hand (usually the strongest one), among other things.

Those features reduce stress injury because they result in less finger movement and more natural dynamics.


However, I think Dvorak actually puts some fingers to even more use than QWERTY? I had pain in my index finger, and it seemed to me with DVORAK I would use it even more, as the most common keys would be put on the index finger. I haven't actually tried Dvorak, though, only looked into it.


Again, please do not downvote people for asking simple questions. In this case, dshah's questions are interesting and personally I'd like to know the answers also.


http://www.jwz.org/gruntle/wrists.html

Step one is to see a doctor about it. Or as jwz puts it, "Do not fuck around. If you are experiencing any kind of pain, get to a doctor and get it diagnosed." Your hands are your livelihood and you do not want to be cavalier about this. Nobody here is qualified to diagnose you from across the Internet. Quoting jwz again, "... think what your life is going to be like if you can't type at all. I have friends this has happened to. You seriously do not want to go there."

Mice with high click resistance have caused me the most tendon pain in my right hand. They seem to be getting much worse in recent years -- I had to replace one recently that took a feather-light touch, and I haven't found anything that comes close. The best one I've been able to find unfortunately doesn't have all the features I would like, but hands that aren't crippled are more important than features:

http://www.amazon.com/Logitech-MX518-Gaming-Optical-Mouse/dp...


First thing: figure out where your problem is. Next time you feel pain, try to determine exactly where it is. Also useful when you talk to a doctor about it.

Then find a map of the nerves in your hand (Grey's Anatomy has one). Find the joints that that nerve goes through, probably one of those is squeezing it. Adjust your position/workspace to avoid stressing that particular nerve.


Yoga (in a workout variant) seems to help the most. A lot of exercises stretch the wrists.

Also, I had a cyst in my index finger and had to get surgery to remove it. The doctor almost didn't discover it, because he wasn't sure if the "common RSI" symptoms would even warrant taking an x-ray. Luckily he decided for it.


This won't help with the current symptoms you have, but when you've recovered:

The best thing you can do is to switch hands frequently through the day. The second best thing you can do is work out in the gym regularly. This will strengthen your fingers, wrists and arms.


I've had it, and it did get better slowly. It cost me many thousands of dollars of lost work. The doctors are pretty useless in many cases.

0. Proper sleep, exercise and nutrition are important.

1. Hit the keyboard more gently.

2. If you're a wide person, like me, your elbows are out to the sides and your hands come in from the sides. So get a split keyboard like the Microsoft Natural. There are plenty of other keyboards that are split and "Ergonomic".

3. I had to drop Emacs, as it overused the ^X and meta-x keys. I mapped them to Function keys but that wasn't enough.

4. Not all RSI is carpal tunnel. There are even other tunnels. The thing about tunnels is that both a nerve and a tendon will go through the same tunnel in bone. When the tendon inflames it enlarges and squeezes the nerve against the bone. Misery ensues. You're body has lots of tunnels. There's even a pair in the head.

5. The best voice software is or was from a company from "Dragon Systems". The business history of this company is fascinating. Their "Naturally Speaking" product might still be the best.

6. Find and talk to some people in your state who have been on Disability. In some states, your Disability claims get paid by the last company you worked for. This results in you being blackballed by the business community. The companies seem to share information on employees and this might be legal. That's what those industry organizations are for, among other things. People who go on Disability are likely to sue. They don't want that. In the US, it varies from State to State. Get local information.

7. In some times and places, Disability is a big con and the bureaucracy has learned to treat all claimants as crooks; you are guilty until proven innocent. This is an important psychological injury and leads to trouble.

8. RSI can cause people to hate their jobs, and hate computers, they become the enemy. Work attitude suffers. Some management knows this and will head of trouble by getting rid of injured employees at the first excuse.

9. Get three different styles of keyboard and two or three mice. You an actually plug them all in at the same time if they're all USB.

10. See a hand specialist and an orthopedist. There is also a chance that what you really have is some outlier; like cancer of the bone in the hands, or something weird. Nerve damage can also be caused by bone weakness or osteoporosis. Have it all checked.

11. Docs tend to look at bilateral problems (both hands) differently. The trouble might be in the common parts, the spinal cord or the brain. This could be good news if they're right, as some mental problems and neurological conditions are easier to treat than soft tissue injuries.

12. Physical therapy can be very annoying but also be very, very useful. Do whatever they say as if it is God Himself commanding you from the Mountain. Do it every day, if they say so.

13. Going Dvorak means a new keyboard for both home and work. Give up game-playing and some web surfing. TV is also bad for you. You need basic exercise, walk or run. No handball, racquetball, tennis, ping-pong, hammering. Make sure you have an electric screwdriver or don't do that at all. I found that swimming stressed my hands.

14. If you take as many breaks as the RSI experts say, your whole level of intensity will go down. I don't even know if it's possible to relax your body as you work your mind unless your a Zen master, or something.

15. If you research the subject, you can terrify yourself and be paralyzed with anxiety. If you research RSD/RSI together, you'll leave work and become a monk out on a mountaintop, and starve to death. Okay, I'm exaggerating, here.

16. Proper sleep, exercise and nutrition are STILL important.

17. You might checkout http://www.rsirescue.com/, I haven't looked that stuff for years...

18. The only way to sit up straight is to raise the monitor screens. If you raise them too high, you'll be looking up, which is just as bad.

19. The most expensive chairs, keyboards, and so on are worth it, financially, if they work. Lost work is more expensive than any of those.

20. In some states, employers have to assume that if you were out of work for a while, you must have been in prison. This is because prison records get sealed after a few years so that ex-prisoners can get jobs and rehabilitate. So if you've been out of work a few years ago and don't have a prison record, you look just like somebody who actually was in prison.


4. Not all RSI is carpal tunnel.

It's funny, but the RSI book a friend recommended to me is titled "It's Not Carpal Tunnel Syndrome!":

http://www.amazon.com/Carpal-Syndrome-Therapy-Computer-Profe...

Contrary to the title, the book doesn't rule out the possibility of carpal tunnel, but it correctly points out that carpal tunnel only applies to a small set of RSI-related symptoms. I found the book helpful.


while it's possible that mentioning it to your employer may have negative consequences, I think it much more likely that your employer will get you what you need as far as an ergonomic workspace. Unfortunately you need to have some idea of what you need in an ergonomic workspace to ask. So if you have the money, try different things at home. You may also be able to borrow coworkers items to try them. Frequently, someone who has dealt with RSI and found some simple solutions will be excited to share whatever helped them.


hi there,

i am 27, and just have had the worst tendonitis ever. adding to the already brought up advices, my doctor provided the following important insight: if your blood contains too high values for uric acid, or you are a candidate for urarthritis, then you also might take some concern for minimizing purines in your diet. so in the long run, you should be interested in keeping your uric acid values low.

ps: usual stuff here too: kensington expert mouse trackball, kinesis freestyle keyboard, xwrits, cycling, using stairs, checking posture, etc. -- switching to dvorak soon...


I switched to dvorak, got an Aeron chair and Humanscale KB tray when my hand started to show signs of RSI... 3 years later I haven't had any more symptoms of RSI.


Mind telling us which machines do you and your friends use? Are those MacBook Pro's by chance? I starteted having quite a bit of problems soon after buying one.


It's a 50/50 split between typical Win PC's, and yes, MacBook Pros. I use a MacBook Pro. Perhaps there is a correlation.


One thing cured my RSI carpal tunnel problems: the dyna-flex ball. You can find it in sports shops and sometimes golf or tennis pro shops.

Edit: found a mention of dyno-flex ball above. This thing is awesome! Plus the usual things of course. I recently bought a Dvorak keyboard but haven't yet started using it. I always use a trackball (Logitech thumb-trackball, the only REAL trackball on the market). Joystick mouse sounds about right too.


What I did, after my 2 years away from computers. It sucked, but I was in real pain.

- Switched to a big logitech trackball, which I use with my left hand - Negative tilt splitted keyboard (microsoft natural 4000, I higly recommend it) - setup my chair/screen height - Xmonad (proper window manager) - minimize GUI usage.

I've been doing ok. I even started drumming (hard!)


I have had the beginnings of that unpleasant tingling at 27, and I make a conscious effort to keep my wrists straight. After a few years, it didn't even feel like an effort. Remember, it's compressing this little tunnel through which a nerve runs that is the problem - that doesn't HAVE to happen while you type.


"hitting keys"

Stop hitting them then. Only use a laptop, and touch them lightly. Don't use a mouse, use a trackpad.


Thanks everyone--some really awesome, useful advice. I really appreciate it!


see keyboard review threads:

http://news.ycombinator.com/item?id=185743

http://developerlife.com/reviews/?p=46

http://news.ycombinator.com/item?id=221434

http://news.ycombinator.com/item?id=199493

http://news.ycombinator.com/item?id=104977

That's about 3 days' reading material: some bullets as i dimly remember:

1. laptop keyboards: avoid, especially for emacs/textmate control/alt/command key combo's. These 2-key to 4-key combo's are hell on your wrists if you always have to do them on the left side. If you do COntrol_C and X and V to cut/past in windows, same deal. I think it helps to use both short-travel scissors mechanism keyboards, like the new aluminum mac KB's and older-style long-travel sprung keyboards taht logitech , Matias and kensington make. I especially like the Matias' feel.

2. hourly breaks and wrist exercises: wrist curls, reverse wrist curls, the Dyno-flex ball , powerWeb exercises. The latter is expanding your semi-closed fingers out against resistance, which is one that I rarely read about, but it's important.

http://www.fitter1.com/Catalog/Category/35/HandWrist.aspx http://www.amazon.com/Roller-Strength-Gripper-Forearm-Stainl...

3. always have your elbows and heels of hand supported weight-wise when mousing and keyboarding (kinda like Formula 1 designers trying to minimize unsprung weight). Try to mouse with undominant hand (I'm not too good at this)

4. consider other factors: cocking your wrists when you drive or ride a bike or work power tools, shovel snow, brush your teeth, sleeping on your side. The combination of weight-bearing, pressure/shock/vibration and closing off the outside or inside of wrist joint is insidious .

5. Aside: i think JFred has enough material for a book. all my upmod points to him/her!




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