A cognitive intervention for wrist pain

Intention

(Added 2019-03-19.)

The web con­tains much in­for­ma­tion about wrist pain, RSI, carpal tun­nel syn­drome etc. Most of it sug­gests that it comes from repet­i­tive small move­ments, such as typ­ing. It warns about dire con­se­quences, and recom­mends im­prov­ing work­place er­gonomics, stretch­ing and do­ing other ex­er­cises. This is helpful when the cause of the pain is phys­iolog­i­cal.

For other peo­ple the repet­i­tive move­ments are harm­less, but stress is the pri­mary cause of the pain. For these the com­mon ad­vice, al­though no doubt given with good in­ten­tion, can lead to a vi­cious cy­cle of pain caus­ing stress caus­ing more pain. I don’t know the pro­por­tion of the two groups, but I be­longed to the lat­ter.

In this ar­ti­cle I pro­pose a way to break the vi­cious cy­cle. Ideally, ev­ery­one writ­ing about wrist is­sues would take care not to plunge the mem­bers of the sec­ond group into anx­iety and pain.

The intervention

I as­sume that your thoughts fol­low this pat­tern:

I have wrist pain. It comes from typ­ing. Typ­ing is a repet­i­tive move­ment that strains my wrists and causes ac­cu­mu­lat­ing in­jury. I can’t stop typ­ing, be­cause it’s nec­es­sary for my job. I am afraid that the pain will get worse un­til I can’t do my job any­more and lose my in­come.

You can prob­a­bly sub­sti­tute any de­sired out­come for ‘in­come’, any nec­es­sary ac­tivity that you think is harm­ful for ‘typ­ing’, and some other lo­ca­tions for ‘wrist’. If your thoughts don’t fol­low this pat­tern, this in­ter­ven­tion might not help you. I’d be cu­ri­ous to read your par­tic­u­lar thoughts in the com­ments, though.

Let’s in­tro­duce three more thoughts. One:

Stress (in the com­mon lan­guage sense – wor­ry­ing, anx­iety, things not go­ing the way you want them to) can cause phys­i­cal is­sues, in­clud­ing pain. Should I be­lieve that? Well, I’ve heard of peo­ple who get a headache when they’re stressed. And some peo­ple get chest pain when they’re anx­ious. There is a whole branch of medicine try­ing to find out when and how our mind af­fects our body. And there are peo­ple who claim that their wrist pain went away af­ter they changed their think­ing. So I should at least as­sign some cre­dence to the hy­poth­e­sis that my wrist pain is caused by stress.

Two:

Typ­ing isn’t nec­es­sar­ily bad for the body. The ma­jor­ity of high-vol­ume typers have no prob­lem with it. (Other­wise it would be a ma­jor pro­duc­tivity crisis in typ­ing-heavy work­places.) And many of them type with­out break on cheapo key­boards, with their wrists bent, not know­ing any­thing about er­gonomics, sit­ting in cold rooms on chairs that match nei­ther their desk nor their height. And the hu­man body is amaz­ingly re­silient in gen­eral. There are sto­ries of pris­on­ers of war who sur­vived be­ing in­jured (bro­ken back and open wounds), tor­tured, and forced to trek through the jun­gle for weeks with lit­tle food and no med­i­cal treat­ment.

Added 2019-03-19: Char­lie Steiner and Chris­ti­anKl sug­gest that wrist is­sues are a ma­jor eco­nomic prob­lem. The ar­ti­cle that Chris­ti­anKl quotes con­tains a hodge­podge of num­bers and I don’t know which I can be­lieve and which not. So I went back to one of the sources. It gives me a prevalence of carpal tun­nel syn­drome (CTS) at­tributed to work of up to 4 % in oc­cu­pa­tions that might be typ­ing-heavy. This is more than I ex­pected, es­pe­cially given that there might be more cases of wrist pain that are not di­ag­nosed as CTS. It might also mean that I’m wrong about the pro­duc­tivity crisis. How­ever, even if the prevalence of wrist is­sues was 10 %, that leaves 90 % of peo­ple who don’t have a prob­lem with typ­ing.

Three (op­tional):

This wrist pain I have is a strange kind of pain. It comes when I type. It also comes when I rest. Some­times it’s there, some­times it goes away. Some­times it’s stronger when I rest than when I type. If it was an in­jury, shouldn’t it slowly get stronger from typ­ing, be­cause the in­jury is re­in­forced, and slowly fade when I rest (es­pe­cially at night), be­cause the in­jury is heal­ing?

Now we have an al­ter­na­tive ex­pla­na­tion for the in­creas­ing wrist pain. It might not be caused by the typ­ing. It might be a vi­cious cy­cle: The pain makes you wor­ried that you might lose your in­come. This is stress. Stress, by the as­sump­tion above, causes more pain. More pain in turn makes you more wor­ried and so on.

If this ap­plies to your case, it also means that the typ­ing isn’t the cause of your pain. So do­ing your job won’t make your pain worse. This means you can stop wor­ry­ing about failing to do your job and los­ing your in­come. The stress goes away. The pain goes away. The vi­cious cy­cle is bro­ken by the as­sump­tion that the be­havi­our nec­es­sary for in­come (typ­ing) doesn’t cause pain, but stress does.

Added 2019-03-19: Ideally you could tem­porar­ily switch off ra­tio­nal­ity, put the as­sump­tions in our mind and ob­serve whether the pain goes away. If it does, it proves that the as­sump­tions are true and that you are one of those cases with a vi­cious cy­cle. If it doesn’t, you re­move the as­sump­tions again and fol­low the com­mon ad­vice about stretch­ing and er­gonomics. Real­is­ti­cally, I hope that as­sign­ing a small cre­dence to the as­sump­tions damp­ens the vi­cious cy­cle/​feed­back loop enough to make it die down.

Of course, you might get stressed by other things like an in­creased work­load, a bad re­la­tion­ship with your boss etc. This stress might cause wrist pain. But it’s not a vi­cious cy­cle any­more. Be­fore you had: Pain → stress → pain. Now you have: Stress → pain (the pain doesn’t sig­nifi­cantly in­crease the stress, be­cause it doesn’t come from the nec­es­sary be­havi­our of typ­ing). How to deal with the stress? Fix your thoughts. Ad­dress the root cause.

Note that by the stress-can-cause-pain as­sump­tion, ‘typ­ing with bad er­gonomics causes in­jury’ and ‘the hu­man body is a very del­i­cate ma­chine’ are self-fulfilling prophe­cies.

Evidence

The above in­ter­ven­tion re­lies on the as­sump­tion that stress can cause pain. If peo­ple re­quest it, I can prob­a­bly dig up some re­search in that di­rec­tion. For now, I hope that my story will provide enough anec­do­tal ev­i­dence to in­crease your cre­dence slightly and this in turn will en­able the in­ter­ven­tion. Grab a hand­kerchief and read on:

Si­tu­a­tion and sever­ity of symptoms

In 2014 I had finished my un­der­grad­u­ate in com­puter sci­ence, started a grad­u­ate course and started work­ing part-time as a soft­ware de­vel­oper. My plan was to ditch the grad­u­ate course af­ter half a year (not a big deal in Ger­many), move to Ja­pan to be with my girlfriend, whom I had met in Den­mark a few months be­fore, and con­tinue my job re­motely.

Nat­u­rally, I was very keen on mak­ing this plan work. I’m also a wor­rier, so I was alarmed [cue om­i­nous brass chords] to feel an oc­ca­sional wrist pain. I knew that my grand­mother had had surgery for carpal tun­nel syn­drome, I had seen the scars on a sum­mer camp tu­tor’s wrists, and I had some­how heard of RSI. So I searched the web and found things like this: ‘When my RSI was at its worst, I was un­able to open doors, pre­pare my own food, do laun­dry, drive, write, type, and shake hands. This lasted for half a year. I was un­able to type reg­u­larly for about three years.’ This page warns about RSI, tells how to pre­vent and treat it. Sadly, if you suffer from wrist pain through a vi­cious cy­cle as pro­posed above, read­ing that ad­vice will make your prob­lem worse. I also watched the talk of a guy who spent months set­ting up Emacs and Dragon Nat­u­ral­lyS­peak­ing so that he could pro­gram with voice com­mands.

In my mind the whole Ja­panese dream was fal­ling apart. So what did I do? I didn’t start talk­ing with my com­puter, but I did buy a Microsoft er­gonomic key­board. I used hobo gloves (qual­ity knit­ting work from my grandma) to warm my hands while typ­ing. I set my lap­top on a box with the key­board in front, so that the screen would be at eye level – good pos­ture! I started stretch­ing ac­cord­ing to Clay Scott’s (they guy who wrote the quoted state­ment) ad­vice. The pain got worse and would per­sist even into the night. So I pul­led socks over my hands when I went to bed. In my dreams my legs would be joined and I would be bal­anc­ing a red ball on my nose… just kid­ding.

The cure

Be­cause the usual recom­men­da­tions weren’t work­ing, I searched the web again and this time I ven­tured to page 2 of Google, where I found – a big turn-off for the ra­tio­nal­ist mind – John E. Sarno’s The Mind­body Pre­scrip­tion. I didn’t be­lieve most of it. When I read sum­maries now, it makes even less sense to me than I re­mem­bered. But ei­ther I’m naive enough that I be­lieve some of the wacky stuff sub­con­sciously. Or all it did was to provide the key thought that broke the vi­cious cy­cle: ‘the pain might not be caused by the typ­ing’. What­ever it was, the pain went away within a few days.

If all the book did was to provide the one key thought, this ar­ti­cle should be enough of a cure for peo­ple like me. If not, give the book a try – it’s not rigor­ous, but it’s tol­er­able. And it’s bet­ter to rule it out be­fore buy­ing ex­pen­sive equip­ment and spend­ing an hour ev­ery day stretch­ing.

What hap­pened since

I’ve been typ­ing for years on var­i­ous key­boards, in var­i­ous places and var­i­ous pos­tures with­out pain.

Some­times my wrists still start hurt­ing. I take it as a sig­nal that I’m let­ting some­thing stress me and ap­ply the three column tech­nique from cog­ni­tive ther­apy to set my­self straight.

Half a year ago my er­gonomic key­board broke and I bought a straight Ap­ple Magic Key­board. When I started us­ing it, my wrists and fore­arms be­came sore, but it felt differ­ent from be­fore. More like my fingers, hand and fore­arms were cramp­ing, be­cause they didn’t yet know how to deal with the new lay­out and feed­back of the keys. Sure enough, the is­sue went away af­ter a few days of in­ter­mit­tent typ­ing.

Let me know in the com­ments if this helped you, and if not, why not.


Com­ment­ing guideline for this ar­ti­cle (added 2019-03-19): This post is for the peo­ple in whom the com­mon ad­vice about wrist pain causes more wrist pain. Hence I don’t want to see the com­mon ad­vice re­peated in the com­ments. You’re wel­come to at­tack my rea­son­ing and give helpful sug­ges­tions.

Ex­per­i­men­tal: This post backs cer­tifi­cate RichardMoehn-2, which is now owned by Richard Möhn.