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I'm not a doctor, but I've seen one and have researched this subject, searching for more information on ways of avoiding CTS and curing it once it has happened. If you believe that you have CTS, please go see a doctor right away, or at least after reading what I've written below. I concentrate on the easy things you can do, in part because they're cheap and easy, and in part because I feel that they are in the long run more effective than the drastic invasive measures that a doctor may recommend as a last ditch effort. Do note that the measures listed below are not in any specific order because I think they're all important, and none conflict with each other, unless you go under the knife.
Ergonomics -- The first thing you should do to prevent or treat CTS is to make sure that your computer environment is well-set up, ergonomically speaking. The basic principle involves right angles. Your feet should rest flat on the floor, your calves should be perpendicular to the floor and to your thighs, which should be parallel to the floor, and the angle between your thighs and back should be at least 90 degrees. Your arms should hang relaxed at your sides, and your forearms should project out straight in front of you, forming another 90 degree angle. Your wrists should be straight, not arched upward. You might adjust your keyboard for this, or you might have to adjust your chair and desk height. Standard typing height is supposedly 27 inches, but that will vary with your height. I had to saw an inch or so off my desk and buy an adjustable chair, both of which helped a great deal.
You should be between 18 and 28 inches from your screen, and it should be adjusted so that it is between 15 and 30 degrees below your straight-ahead line of sight. If the screen is much lower than that, you'll probably end up slouching.
Wrist Pads -- By now you've probably seen the neoprene wrist pads that many people put in front of their keyboards. I highly recommend you buy one (about $10) because they help in two important ways. First, when you type, you shouldn't rest your hand on the desk, but many people do. The wrist pad is designed to remind you to lift up slightly so your hands don't rest on any surface as you type, because that angle can compress the carpal tunnel. Secondly, when you stop typing to think, you probably put your hands down, and it's better to rest them on a soft pad than on the hard corner of a desk, which can cut off circulation and compress the carpal tunnel.
I'm convinced that these pads, simple as they are, help a great deal. Microsoft gives a wrist pad to every employee. Microsoft's wrist pads are unimpressive compared with the one I've been using from Silicon Sports. Generic wrist pads consist of a piece of neoprene or similar rubber padding, whereas Silicon Sports has a better design with two layers of padding under the colorful top covering. The lower layer is the standard dense foam rubber, but the thinner layer on top is a softer foam than the generic pads use, and I found it noticeably more comfortable. Silicon Sports also has a pad for the PowerBooks coming out soon and a clever wrist pad/mouse pad combination that fits together like puzzle pieces and keeps everything compact. Get one of these wrist pads and use it. Depending on your office-mates, it might also be good for whacking them on occasion. (Kids! Don't try this at home!)
Silicon Sports -- 800/243-2972 -- 415/327-7900
Chill Out I -- Take a break and relax. I suspect you work too hard and put in too many consecutive hours at the keyboard. You should take a break every 45 minutes or so, and by a break I mean that you should actually do something different, like go hang around the water cooler or hassle a coworker (Dan Quayle's Council on Competitiveness will have me shot for that statement.). You can do some simple exercises as well, the easiest of which are (a) gently squeezing a rubber or foam ball in your upward-facing palm and (b) extending your fingers completely until you feel a stretch, then relaxing your fingers and curling them in toward your palms.
LifeGuard -- Visionary Software has a useful little DA called LifeGuard that can nag you into actually taking these breaks. It monitors how long you're typing or mousing, and then tells you to take a break. You set the length of both the work time and the break time, and it will give you either an audible reminder or a dialog reminder that suggests something else (which you can set) to do. LifeGuard also has a useful section on exercises (including the ones mentioned above) and another one on ergonomics. Lifeguard has a number of limitations, and I'd far prefer it if you could pick a set of sounds for it to choose from randomly and if it had an option to literally lock the screen to kick you off, but it's cute and useful.
Visionary Software -- 503/246-6200
Splints -- One of the easiest things you can do that a doctor will also recommend is to get wrist splints and wear them in bed, if not also during the day. Most drugstores should have them in different sizes and shapes, although all the ones I've seen are a vague tan color. I'd like to see them in black, bright blue, and even perhaps some fluorescent colors. There's no reason they have to be ugly, and it would be nice if their velcro wasn't quite so exposed. I hate sticking to everything!
The splints are generally called "cock-up splints" or something similar because the metal splint cocks your wrist at a 20 to 30 degree angle. This position is neutral, so in theory you aren't compressing the carpal tunnel while wearing them. I also find that certain life activities, like driving a car without power steering or pushing a shopping cart, are extremely hard on damaged wrists. The wrists splints provide welcome support in those cases, but I do wish they didn't look so stupid.
Vitamins -- My doctor recommended that I take vitamin B6. Apparently the omniscient "they" have done studies showing that vitamin B6, in doses of 100 mg daily, can help cure CTS. Apparently B6 plays a role in producing neurochemical transmitters, and that can help. You can find B6 naturally in brewer's yeast, wheat germ, and blackstrap molasses, but if you're like me, your diet doesn't include those three items regularly. Supplements are probably in order.
Another vitamin that may help is vitamin E, in 400 IU doses before bed. My doctor mentioned it as well, and my father had excellent luck with it clearing up his arthritis in his mid-thirties. I've taken it on and off when I'm running competitively because I find that I tend to get shin splints otherwise. Medical science is still undecided about vitamin E, and the only things they've proven, I believe, are that it reduces free radicals (a laudable goal) and it prevents impotence in rats (an equally laudable goal).
Chill Out II -- This time I mean it literally. Current medical thought believes cold is much better than heat for aiding healing. The basic idea is that cold reduces inflammation, whereas heat may reinforce it. Also, since nerves are extremely sensitive to heat, heating aching hands may feel good, but it's deceptive because all that's happening is that the nerves that were transmitting pain impulses are now sending heat signals.
Probably the best way of applying cold to your arms is via ice massage. If you freeze water in paper cups, you can then rub your arms with the frozen cup, gradually tearing the cup away as the ice melts. It's messy and not terribly ecologically-conscious, but it works and lots of athletes use it to reduce pain and swelling after exercise.
A tidier method is to go to a sports store and pick up four or five of those ice bags that have some sort of blue gel in them. They're cheap and they work well. Don't overdo the cold. Frostbite isn't fun.
Massage -- Gentle massage on the hands, wrists, arms, and shoulders (which may often be tight and sore too), may feel good, especially if someone else does it, and you can also use a hand lotion that has vitamin E in it, just in case some vitamin E is absorbed through the skin. No clue if that's true, but I've had good luck with using it in massage.
Exercise -- When I first admitted that I had CTS, I thought a bit about what I could do that doesn't involve my hands. Other than being a couch potato, which I don't approve of, all I could think of is running. It was an excellent excuse to get out on the trails regularly. My doctor agreed that exercise was excellent, in part because it doesn't use the hands, and in part because it helps relax both the body and the mind. I'm not going to recommend that you all immediately become distance runners, but exercise-induced endorphins are good stuff (now I'll have a drug czar on my case).
Standard warnings about overdoing it apply here too. You may not think about it normally, but if you're having trouble with your hands and wrists, be careful not to clench your fists when you run, and avoid shaking your hands at the wrist. Of course, walking is good, and swimming may be, although I find that it tends to put a bit too much pressure on my wrists, depending on which stroke I use. Bowling is right out.
Alternative input devices -- Definitely look into alternative input methods that will reduce strain on your hands and wrists. The most common of these devices is the trackball, and next week we'll look at two well-designed trackballs, the CoStar Stingray and the Curtis MVP Mouse and Footswitch. Trackballs are often more comfortable because the mouse click & drag action requires a significant downward pressure, and that pressure requires additional force to move the mouse horizontally. Also, moving the mouse with your wrist and arm is more likely to compress the carpal tunnel than similar movements with a trackball, which requires only the use of the fingers.
More esoteric input devices include chord keyboards and voice controllers. Chord keyboards may help reduce CTS problems because you don't have to move your hand at the wrist to reach all the keys. A chord keyboard arrays its small number of keys so your fingers are always on the correct keys, and all you have to do is press the proper combinations. It may sound awkward, but I'll bet it took you more than an hour to learn to touch type on a standard QWERTY keyboard. We'll have more on Infogrip's BAT chord keyboard in a future issue, and you can get more information from the files stored on our fileserver.
Voice controllers are definitely neat, but they must be trained, are sensitive to changes in your voice, and can only do the sort of things you can do with QuicKeys. The Voice Navigator demos are impressive, with the slick salesman quickly drawing their logo by voice. He sounds like he swallowed an auctioneer. However, the problem is accuracy, not speed. Apple's Casper technology promises to be pretty snazzy when it ships with the next generation of high-end Macs, but I'm not holding my breath. Finally, none of these systems will do dictation - for that you need a costly speech recognition system.
Simple Drugs -- Doctors will recommend aspirin or ibuprofen early on. They may also provide a prescription for more potent stuff like Feldene, which is much stronger and has more side effects. Remember, drugs merely treat the symptoms, and unless you're in a situation where the symptoms prevent the body from healing itself, drugs may provide only temporary relief. You can't take this stuff for the rest of your life.
Relaxation -- OK, you've read all of my suggestions, but I will venture into left field here and claim that none of it will help unless you reduce your stress level. Since I've had CTS, I've talked to a number of people who have successfully defeated it in interesting ways. One swears by Tai Chi, a martial art that involves slow, deliberate movements and heightened consciousness of your body. Another had CTS so badly that they hospitalized him and gave him morphine for the pain. Surgery cured the CTS, but didn't reduce the pain. It wasn't until another doctor put him on a stress reduction program that he started to recover.
Another name for CTS-type injuries is cumulative stress injuries because you are essentially stressing a certain part of your body thousands of times an hour, and the body can't handle the stress. Mental stress will cause physical reactions as well, and the guy I spoke of above who had surgery didn't experience reduced pain until he was able to relax and break the stressful mental pathways he'd built up.
Support for this theory also comes from a study showing that early symptoms of CTS were twice as a common among communications workers who were electronically monitored than those who weren't, possibly because of lower stress levels in unmonitored workers.
I suggest that you can and must reduce your stress level to allow your body to heal. From what I've read and heard, you have a variety of choices on how to go about this, be it yoga, Tai Chi, meditation, a non-violent martial art, or even acupuncture. I suspect it will be hard for many of you, being rational computer-types like me, to try one of these methods wholeheartedly, although I gather people become much more accepting when the alternative is the knife. I also highly recommend that you look for a book called "Freedom From Stress: A Holistic Approach" by Phil Nuernberger (ISBN 0-89389-071-5). It combines well-explained scientific evidence along with advice on ways to reduce stress using the theories of yoga as a base. Do with that advice what you will - I'm trying it.
Icky things -- I don't want to talk about this much, but if you let wrist pain progress too far, Western medicine will almost certainly want to give you drugs or cut you open The first move is a cortisone injection into the wrist. This is painful and doesn't always work. Doctors generally try injecting you up to three times at intervals of three weeks. If you're lucky, the pain will recede by three days after the injection. Some people have great luck with this treatment. Others don't.
If you're not lucky, you progress to surgery. The basic principle is that the doctor can release the pressure in the carpal tunnel by slitting it so that it can expand slightly. Some people do well after this process and return to normal work several months later. However, if you don't treat the causes of CTS, you can just get it all over again. So do yourself a favor and try the stuff I suggest above wholeheartedly before you submit to the needle and the knife. It can't hurt, and I sincerely hope it helps a great deal.
