Articles / My Ergonomic Nightmare

My Ergonomic Nightmare

A couple of years ago, I experienced the worst form of Repetitive Stress Injury, leading up to the dreaded Carpal Tunnel Syndrome. I responded by reducing my time with the keyboard, using ergonomic gadgets, following every bit of advice I could find, seeking medical help, adopting voice recognition software, and undergoing physical therapy, none of which provided a lasting solution. Not to be content, I kept looking for a permanent cure. Eventually, I found the cure in Muscle Learning Therapy, which brought about a remarkable recovery. In this article, I recount the experience of living through the trauma, despair, and recovery.

The Pain

It was my worst nightmare come true. Every keystroke required an extra effort, every mouse click an extra determination. Even simple chores, such as picking up the pen and writing on paper, hurt. Changing postures, adjusting and readjusting the keyboard tray height and inclination, and setting and resetting the chair knobs only moved the pain points. Sometimes, it was soreness in the veins on the back of right hand. Other times, it would show up as hardness at the back of the right forearm. Yet other times, it would be extra tenderness of the front of the forearms. To top it all, I would feel the tingling feeling near the fingertips at night, as I lay wide awake.

It didn't happen all of a sudden. I had felt discomfort moving and clicking the mouse for quite some time. Continuous keyboard use for prolonged durations also hurt. In the beginning, I thought I just needed to slow down. I scaled down my ambitions, took time off, reduced my time in front of the computer, and did everything possible to minimize my keyboard and mouse use. All this helped, but not much. I was far from feeling normal.

I talked to colleagues at work about it, and was surprised to learn that I was not alone. Also, I got good advice -- get an ergonomic evaluation done. I followed the advice, and a got my workplace evaluated by an ergonomics expert.

The evaluation led to certain changes in my workplace configuration: The desk was lowered by an inch. A keyboard tray was installed. The existing mouse was replaced by one with much softer click buttons. I was prescribed a strict regimen of mouse and keyboard use: Keep the mouse close to the keyboard and keep the keyboard close to your body. Essentially, don't reach out for normal and repetitive work. There were numerous other pieces of advice.

I tried to follow most of these with varying degrees of success.

I could feel that all these plans were helpful, but they didn't make me feel and behave normally. In fact, the pain worsened with time. That this was happening in the 10th year of my software career, with each year filled with long hours in front of the computer, amazed and frightened me. The question that kept bothering me was the timing. Why now? I had programmed and typed and moused since my Sophomore days. Everything was all right for more than twelve years. What had changed now? Of course, I had moved from India to the U.S. a year ago, and that was a big change. I was sitting in a different workplace and was driving a different car. Were these the reasons? I didn't spend a whole lot of time on the wheels, and the ergonomic reconfiguration of the workplace should have addressed workplace setup issues.

My ergonomics counselor had an explanation: wear and tear of body tissues with aging and repetitive use. Though plausible, I had difficulty in accepting this reasoning... partly because it offered no hope.

Those few weeks were full of confusion, self-doubt, and low confidence. I would blame my profession, which necessitated typing and mousing. I would contemplate quitting the job, returning to India, and doing something that would keep me away from computers. In fact, I did take time off for vacation and went to India for a few weeks. The vacation was wonderful -- the pain was completely gone. However, the very first day at work nullified all the healing. It was no better.

A Visit to The Doctor

The pain was starting to have an effect on routine activities other than typing and mousing. Driving the car, turning the doorknob, holding up my daughter Akriti, moving household stuff... Nothing was painless. The constant tingling at the fingertips was also a constant reminder that everything was not all right.

Finally, I decided to pay a visit to my Primary Care Physician.

My physician diagnosed my condition as Tendonitis, a previous stage to the dreaded Carpal Tunnel Syndrome. Other than the diagnosis, he had little to offer. He prescribed Aleve, an over-the-counter medicine for pain relief, but suggested no long term solution other than avoiding the computer altogether.

Back at home, I surfed the Internet to find more information on Tendonitis and Carpal Tunnel Syndrome. What I found was not pretty. All this depressed me even more.

Aleve did reduce the pain and the constant tingling of the fingertips was gone. However, the doctor had warned me not to use the medication forever. Sustained use could make me immune.

The relief from pain gave me a chance to think rationally about the whole situation and seriously consider alternatives.

Moving to Voice Recognition

My ergonomics counselor had talked about the use of voice recognition software as an alternative or companion to such I/O devices as a keyboard and mouse. I had not paid attention then, but now, running out of options, I decide to explore further.

One Saturday morning, I went to the local Fry's and bought a copy of Dragon NaturallySpeaking, voice recognition software. Installation on my Windows98 system was straightforward, though getting the configuration right so that it worked with the supplied headset took some trial and error.

Those who are familiar with voice recognition software know that the technology, although quite advanced, is far from perfect. It works by building a database associating soundwave patterns with English words. To account for individual accents and speed of speech, the user must go through a process of training the software by reciting known passages. This helps build and fine tune the database. This database, along with a number of other heuristics such as the relative frequency of words, grammatical correctness, and so on, is used to match the wave patterns of a spoken word with an English word. Small variations such as a minor cold, background sound, and even a change in the distance of the microphone from the mouth can cause poor recognition.

Training the software was a frustrating exercise. My heavy Indian accent didn't help. Still, I persisted. The first few days were tough. It made too many errors, and as a result, took too long to transcribe even simple sentences. Invariably, I would return to the keyboard.

However, as advertised, the software got better with use, and I was getting more and more comfortable. I would spend a couple of hours dictating paragraphs from my early writings and other sources every day. In the beginning, it made many more mistakes, and I had to make the corrections. Every correction trained the software, and it became better at recognizing my pronunciation and accent. With time, the recognition accuracy improved considerably.

Encouraged by this success, I started using Dragon NaturallySpeaking at work for composing mail in MS Outlook, preparing MS Word documents, and even making Power Point presentations. It was not that I was not using the keyboard and the mouse at all. They were there, and I used them frequently to do tasks that were too complex, or when I was in hurry. Still, the use of voice recognition reduced the need to use the keyboard and the mouse significantly. All this resulted in a decline of the occurrences and severity of hand pain.

My ergonomics counselor was very appreciative of my success with voice recognition software; she had seen few succeed with it. Apparently, very few had the patience that it demanded.

Once, she came down to my cubicle to observe me in action. Unimpressed, she made numerous suggestions -- use keyboard shortcuts for menu items, define macros for repetitive sequences, get a better audio card and microphone, put more RAM in your system. I followed most of these, and was able to get the recognition error rate down further.

All along, my colleagues sitting in nearby cubicles showed remarkable understanding and patience. Once in a while, I would ask them if the constant talking to the computer bothered them. They would invariably answer in the negative. I don't know whether they really meant it or were just being nice to me. In either case, I would remain very thankful to them.

Months passed. I had gotten used to this new arrangement and was doing quite well. However, I had not done any coding all these months, and had almost given up any hope of an active programming career. My current role as a development manager was a big help here. Once in a while, I did miss the action, and felt incomplete.

Physical Therapy

The programmer within me was not happy. I longed for the days when I could just dive into the world of infinitely moldable software and turn ideas into lines of code and working programs. I even attempted dictating programs, but was frustrated by Dragon NaturallySpeaking's inability to cope with non-English source code files. Voice recognition was a compromise at best. I also noticed that any increase in the workload would translate into excessive use of voice recognition, leading to soreness of the throat, as well as more typing and mousing, causing a return of hand and wrist pain.

Finally, I contacted the Health Resources department of my company. They referred me to Novacare under the Workers Compensation Program. At Novacare, Dr. Jaishri Ramesh did a preliminary examination and prescribed physical therapy in two sets, each consisting of eight one hour sessions, twice a week.

The physical therapy consisted of therapist-assisted muscle strengthening exercises, electrical stimulation, massage, and ice padding of inflamed tissues. These were all very soothing, and I actually liked them. I could feel more strength in my hands, and was able to do more typing.

At the end of these sessions, Dr. Jaishri advised that I try biofeedback therapy with Dennis L. Ettare. She did mention that his techniques are different, but I had no idea what I was getting into.

Muscle Learning Therapy

I entered the office of biofeedback therapist Dennis L. Ettare with curiosity and trepidation, but not much hope of a real recovery.

Dennis L. Ettare started with a self introduction, a fair dose of causal analysis, and a brief heads up on computer-assisted therapy. He said, "I have been involved in the study and research of biofeedback techniques for over 20 years, and have developed a specialized therapy called Muscle Learning Therapy, or MLT, to promote the reduction of injuries. We will start the session with first talking about the root cause of Repetitive Strain Injury pain, and then about understanding the rationale behind the therapy."

"In order to feel pain in any part of body, those parts must have pain receptors, but muscle fibers, where you feel the pain, don't have these. This has confounded researchers for a long time. It is only recently that we have come to understand that there are hard capsules surrounding pain receptors inside small anatomical sites called muscle spindles. Research has shown that these receptors get fired when people are overloaded, intense, or too focused. The combination of doing more things and doing them faster, aided by faster tools and increased workload, is the real cause of muscle pain. This leads to the conclusion, supported by a good deal of research, that the high performing, conscientious, and focused worker is more likely to be injured."

"There is a scientific explanation for this phenomenon. When a person is overwhelmed or is in a hurry, the chemical and physical response of the body is to get into a state of heightened arousal. This activates a section of the nerves that terminate directly in the same muscle spindles surrounding the pain receptors. This was (perhaps) needed 2 million years ago to respond to fight or flight conditions such as facing a saber-toothed tiger. In today's intense working world, it is an exaggerated response."

"The good news is that you can train your body to acknowledge these intense work conditions as normal and change your fight or flight response by reducing muscle loading. Correction of overly-responsive muscle behavior is the only way you can get rid of the pain and continue to do your job."

"Biofeedback therapy is all about learning the skill of controlling your muscle response by repetitive cycles of control, feedback, and reinforcement."

To be fair, it wasn't such a monologue. Still, I found the therapist, who preferred to be called just Dennis, quite loquacious and repetitive, but understanding, always acknowledging the repetition but also reminding me that understanding the causal analysis was an important part of the therapy.

This is how the first session ended. I wanted to believe every word. After all, these were the only words of hope I had heard in a long time. But deep down, I was incredulous.

The second session had more action. I was wired with muscle tension sensing probes all over my body. These wires were connected to a wireless transmitter attached to my waist. The transmitter relayed the readings to a wireless receiver connected to a computer capable of plotting the magnitude of muscular tension against time. Dennis measured these for different muscles -- upper left back, upper right back, lower left back, lower right back, left shoulder, right shoulder, back of left forearm, back of right forearm, and so on -- for different activities -- sitting, standing, standing up, sitting down, walking, concentrating to balance a tennis ball on a hand-held piece of flat cardboard, doing so while walking... During these measurements, Dennis pointed out the high level of tension in muscles when none was needed. This was a quantification of my undesired muscular response. The aim of the therapy was to improve the individual responses with the constant feedback on how I was faring.

Subsequent sessions focused on reducing the muscle tension when none was needed. For example, while standing still, there was no need for my back and shoulder muscles to tighten up. I learned various techniques -- letting the hands "hang" freely, letting the chest sink, resting on lower back, etc.

Dennis kept reminding me that I must make the learned behavior part of my daily life. "Practicing during the training sessions is only a small part; don't take this as medicine that will miraculously cure you. Take the realization of stiffness and pain as a cue. Whenever you catch yourself in a state of arousal, whenever you feel the pain and stiffness, remember the practice sessions, and control your response."

In spite of my skepticism, I tried my best to follow these instructions. There was nothing to lose.

To my surprise, I felt measurable reduction in pain and overall improvement by the fifth session. I was doing more typing and hurting less. As training sessions became less frequent, from twice a week to once a week and then once in two weeks, I concentrated on practicing the learned behavior at the workplace. By the tenth and the last session, I was able to do most of my work without voice recognition. The volume of typing and mousing was still substantially less than what I was used to during my early years, but a lot more than the one hour or so I could do after physical therapy.

During training sessions, one of the measures of success was the number of peaks and troughs I could create on the computer screen by consecutive stand up and sit down movements. A body movement, either during standing up or sitting down, caused muscle tension and corresponded to a peak. A still position, either standing or sitting, afforded relaxed muscles and corresponded to a trough. A better response, measured by the speed and amount of control of muscular overloading, translated into higher numbers of peaks and troughs in any given time interval.

I became quite good at this test, and Dennis was visibly appreciative. "Twenty. Wow!! The record so far is only Twenty Two. You are very close." His acknowledgement was a real reinforcement for me.

We also practiced muscular response during typing and mousing by keeping the keyboard and mouse near the tummy to avoid reaching out and straining the shoulder muscles and by gliding fingers effortlessly over the keyboard. I also practiced how to take advantage of some of the ergonomics gadgets like a split adjustable Goldtouch keyboard and a mouse with a tracking wheel, though Dennis kept emphasizing the importance of controlling the lower back muscles more than anything else.

The Recovery

The recovery was fast, much faster than in my wildest imagination. Use of Dragon NaturallySpeaking reduced drastically and, after a few weeks, completely stopped. I became less and less selective in responding to mail and was even drafting mail and documents that I wouldn't have imagined just a few months ago.

Within a few weeks of completing the MLT, I was contemplating activities involving significant typing like setting up my own Web site, a long cherished dream, and writing small programs to brush up my programming skills. I was feeling normal.

My work life returned to normalcy. Once in a while, I do experience the return of pain, but these episodes are short-lived. The skills learned at MLT sessions have proved lasting. I have been able to spend long hours at the keyboard, firing off email, writing code, and playing with preview products, much like in the old days.

Today, after more than one year has passed since the last MLT session, as I write these paragraphs and relive the nightmarish experience and the spectacular recovery, I am filled with a strange emotion -- an emotion mixed with confidence, triumph, and satisfaction. I also feel a deep sense of gratitude towards my family, my employer, my colleagues, the superiors, the therapists, and all the others who stood by me. My wife Veena was most supportive, willing and ready to weather any eventuality. My company, Hewlett Packard, had all the policies and infrastructure in place to cope with the situation, be it ergonomics counseling, an on site physical therapy facility, or a worker compensation program for outside treatment. Colleagues bore the inconvenience of constant chatter to my computer without any complaint, and never let me feel my inadequacy in any way. It was this support that kept me going strong as a professional, so much so that most of my superiors didn't even feel any difference in my productivity or professional competence.

References

Recent comments

14 Mar 2003 11:55 Avatar pankajkumar

Ettare Pain Clinic info
Sumit sent me this information:

I found the Ettare Pain Clinic info in San Jose:

4155 Moorpark Ave Suite 21
San Jose, CA 95117

Phone no. 408-782-1200
and 1-800-222-5552

Doctor's name is: Seth Hodge

Some people were looking for info in your article.
Can you pl. update it there? Otherwise, I need to
register myself.

Thanks,
sumit

12 May 2002 21:33 Avatar mystran

Preventive steps...
I had some problems like this when I was about 16 or 17. That time I was using computer something like 3 or 4 hours a day, sometimes longer, mainly writing code or something. It wasn't so bad, but it was bad enough to be pain sometimes, and enough to make me think, whether I would have any chance to do programming or something else like that as my profession.


I am fine now, and am spending some 7 to 14 hours a day on my computer at both home and work, but I have no problems whatever anymore.


I now realize what helped me might be something similar to this. For completely unrelated reasons I was, and still am, interested in meditation at that time. That teached me how to relax my muscles, and also to keep them relaxed when there was no extra work needed. I think my troubles with prolonged computer use are now gone, because I now keep all my muscles relaxed if possible. It makes me feel better overall too. I also feel that doing short walks every half an hour or so is very refreshing to muscles (walking outside building to smoke a cigarette, or just walking to the coffee machine generally is enough for me).


One extra thing I have found very helpful. At home I have my screen next to my bed, and wireless keyboard and mouse to use from my bed (mouse being optical is a must though) so I can be in any position that feels comfortable.


I still feel tension in some muscles when there's a particarly bad problem to be solved, which really makes sense after reading your article, but the meditation stuff has helped me focus my energy to the problem while keeping my body relaxed at the same time.

16 Mar 2002 23:26 Avatar pankaj2002

Re: Now that you can type more, why not write more?

Thankyou so much. I am flattered. Really.


The thought ( of techno-journalism ) has not escaped me. And look at the coincidence -- today was the first day of my dabbling with something what you suggest: two postings at www.theserverside.com ( I hope, freshment.net won't mind the self-promotion :-) ):


1. Java, Apache and Opensource (http://www.theserverside.com/home/thread.jsp?thread_id=12466#43652)


2. Specialized benchmarks for J2EE (http://www.theserverside.com/home/thread.jsp?thread_id=12489#43649)

16 Mar 2002 20:57 Avatar test

Now that you can type more, why not write more?
Greetings,


This short note is to say what I can confidently claim is inline with the opinions of many people who read your article - you are an excellent writer.


Subject matter aside (points for relevancy), this article is the most well-written computer literature I have seen in _years_. I believe your style alone is quite a lesson to others, certainly a worthy model for technical forum submissions, and the computer industry would be a better place with such quality papers. While slashdot may never be able to produce such cogent material, the ACM and Kuro5hin (et al.) could certainly aim this high.


Please, consider extending your authorship from programmer and manager to at least as far as technical journalism. Writing is clearly a large part your Life's work. You are a very talented, and the time and effort you put into this article is very much appreciated. I eagerly await more material on any subject from you.

Thanks!

15 Mar 2002 20:49 Avatar pankaj2002

Re: MORE INFORMATION

> Pankaj-
>
> Where can I find more information on
> MLT? I am in serious need. I have been
> experiencing many of the same symptoms
> as you. I have been through months of
> rehab, take aleve every day and my pain
> is still there. I constantly worry about
> my condition. I have wondered if I
> should quit and find a new career also.
> I am only 27 years old and I am
> seriously concerned. I have had this
> pain for over 4 years now. I have
> controlled some of my symptoms but once
> I control one the pain moves up or down
> my arm. It is currentlly in my neck and
> shoulder region. Please help me with
> more information anything will help.
>
>


Hi Rhet,

Sorry to learn about your situation.

Only places I can refer for more information are already mentioned in "My Ergonomics Nightmare" article and a followup mail:

1. http://www.tifaq.com/articles/commonwealthclub-feb98-dennis_l_ettare.html
2. http://www.biofeedbackcalifornia.org/BSCsummer01.pdf

You certainly can try self-therapy. The things that have helped me most are:

-- Use a keyboard tray that is almost on your lap, so that your hand muscles don't have to go through extra strain while typing.
-- Use a low back chair which gives rest to lower back muscles.
-- While not typing ( say while walking or driving ) let the hands hang freely over the shoulder. I have found this ( letting the hands hang freely ) while doing brisk walk ( on a treadmill ) to be quite therapeutic. As noted by some of the comments, and also in my own experience, there seems to be some truth in the fact that doing regular exercise releives the ergonomic pain.

I wish Dennis was alive and wrote a book on MLT !!

Regards,
Pankaj Kumar.

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