Motion-Based Ergonomics
Keyboard Retraining

Over the years, computer-related injuries (known as repetitive strain injuries or RSIs) have increasingly plagued the modern office workplace, debilitating hundreds of thousands of workers, causing pain, impairment and, in some cases, disability. Workplace measures to prevent or resolve these injuries often include schedule changes, improved body alignment, and reorganization of the VDT workstation. While these strategies may improve or in some instances even resolve the situation, many people find their injuries persist despite these changes. In fact, according to the U.S. Bureau of Labor Statistics (1996), RSI has become the nation’s leading work-related illness, accounting for 64% of all filed worker’s compensation claims with an associated cost of $20 billion a year.

The vast majority of computer-related injuries can be attributed to specific faulty movements and awkward postures inherent in the act of typing, which may cause fatigue, inflammation of muscles or tendons, compression or entrapment of nerves, as well as pain or weakness in the upper limbs and neck. Recognizing and correcting these movements is at the heart of a new and emerging field known as keyboard retraining, a largely overlooked but critical component in the fight against RSI.

Most of us learned to touch-type in high school, or in a typing class, while others are self-taught. Once we have learned, we tend not to think about how we are performing the act of typing, we just type. However, while your typing movements certainly feel familiar, you may be putting yourself at risk for developing RSI. Ask yourself when was the last time you noticed what your hands were doing while typing? Was it in your touch-typing class in high school or your last ergonomic evaluation? Repetitive strain injuries occur for a reason. To help you better understand RSI and its causes, let’s take a closer look at your hands.

If you drop your hands at your sides you should notice the soft quality of your muscles, the natural curve of your fingers, and the alignment of your wrists. Keeping your hands at your sides, wiggle your fingers in a quick, fluttery fashion. This should feel relatively easy to do. Next, curl your fingers in towards your palm (claw), and now try to wiggle them again. Can you feel the increase in tension? Try going back to fluttery fingers. Is this more comfortable? Compare your fluttery fingers to moving with very straight fingers. Lastly, keeping your arms at your side, try bending your wrists back (palms facing the floor) and move your fingers. Would you elect to move like this eight hours a day? Four hours a day? Even one hour?

Yet, it is precisely these kinds of movements that can be correlated to such repetitive strain injuries as carpal tunnel syndrome, ulnar nerve entrapment, lateral and medial epicondylitis, DeQuervain’s tenosynovitis, myofascial neck pain, and others. Although movements vary from person to person, most of us type with our fingers curling, reaching, and moving at extreme ranges of motion that can cause excessive tension and strain.

Case in Point: "Home Row"

If you look at the configuration of the traditional home-row keys, you will see that they form a straight line. Now, look at the natural contour of your fingers. You’ll notice that they create an arc. In order for the middle and ring fingers to "fit" the home row, they have to curl or flex, forcing the hand out of its neutral resting position and producing a most uncomfortable "claw," which creates tension in the fingers, wrists, and even elbows. In an effort to relieve the tension in our hands and wrists that the home-row "claw" creates we often "drop" our wrists (dorsiflex) by resting them on a wrist rest or computer edge. An additional hazard is an awkward and dangerous wrist angle that occurs when we twist our hands outward (ulnar deviation), trying to line up our fingers squarely with the keys.

If the home row as we know it is so problematic, then perhaps it is time to develop a new one that actually fits the hands. Instead of placing your fingers on home-row letters:

try placing them on these letters:

Can you see how the new home row honors the natural contour of your fingers? In this position, your fingers should be gently curved, allowing your wrists and hands to balance comfortably over the pads of your fingers. Try comparing the old home row to the new one a few times. Which one does your hand prefer?

Navigating

Now that a healthier hand position has been established, we are still left with the task of navigating around the keyboard. The traditional touch-typing method instructs us to type with "static" arms and "busy" fingers. We are taught to use the home row as a fixed reference point, from which the fingers both depart and return. Although this system allows letters to be "found" by a sense of feel, it also invites stressful movements. This method requires the forearms to stay static, while the fingers and wrists to do all the work by way of flexing, extending, twisting, and reaching. Just as we would never walk using only our toes and ankles, typing shouldn’t be done with just our fingers and wrists. Instead, we can recruit help from the forearms, elbows, upper arms, and shoulders to reduce finger and wrist movement.

When typing, our fingers typically perform three distinct movements:

• move up and down
• move in and out in order to get from keys in the upper rows to those in the lower rows
• move side-to-side to get to keys on the left or right side of the keyboard

Instead of using those motions to get around the keyboard, you can learn to drop into the keys, using your fingers, hands, and forearms together in a synchronized effort. You can accomplish this by lifting and dropping onto the keys from the elbow "hinge," much like a hammer tapping a nail. This allows your fingers to drop onto the keys with very little effort, especially if you use the weight of your hand and arm, working with gravity as an aid. Motions should never be initiated solely from the fingers, wrists or arms; rather, the whole apparatus needs to move in unison, sharing the workload.

Once you get the hang of "pawing" instead of "clawing," try the following movements to help you get around the keyboard more comfortably:

• Instead of flexing and extending your fingers when moving "in and out," try moving your whole hand forward and back by gently swinging from your shoulders, thus allowing your elbows to take your fingers back and forth without disturbing the natural contour of the fingers.
• To avoid ulnar deviation at the wrist and stretching the fingers apart when typing, try swinging your arms side-to-side through internal and external rotation at the shoulders, moving them like a windshield wiper. The fingers should never have a feeling of reaching or spreading apart for a letter, as this will create strain and fatigue.
• Watch the direction of your thumbs. If your wrists are too low, your thumbs will point away from the keyboard. Make sure your middle fingers aren’t curling, as this will make it difficult to keep your wrists balanced above your fingers. Try raising your wrist height enough so that your thumbs point toward the keys.
• Use gravity as an aid. Your arms weigh more than the keys. There is no need to press, push, or pound on the keys, especially if your wrists and arms are following your fingers into the keys.
• Divide and conquer when it comes to shift keys and key combinations. Most keyboards have two sets of shift keys as well as ALT and CTRL keys. This allows you to use two hands for shifting and key combinations.
• As a general rule, do not rest your wrists on your wrist rest or computer edge while typing.
• In between typing, you may rest your hands and wrists, but make sure not to have your fingers "waiting" in the air. Everything needs to rest.
• Make any ergonomic changes necessary to allow for healthy sitting postures and mobility of your arms. Also, sit high enough so that your elbows are level with or slightly higher than your keyboard.

Remember, your body was designed to move. Ergonomic keyboards and mice can help facilitate healthier body alignment, but if you continue to type with static arms and busy finger movements, problems will persist. Any symptom of fatigue, strain, or pain is a sign that something you are doing is wrong. These suggestions are just the tip of the iceberg with regard to keyboard retraining, but they do provide a good start. Keyboard retraining takes time, understanding, and commitment to change and it begins with an awareness of what you are doing. So the next time you sit at a keyboard, start looking at your hands while typing. Learn to see when your hands lose their natural contours, feel where and when tension is occurring, and begin exploring alternate positions and movements to alleviate your strains and pains.

About the Authors
Norman J. Kahan, MD, a physiatrist (specialist in physical medicine and rehabilitation), and Vivienne Griffin, a concert pianist, have developed the Motion Based Ergonomics™ (MBE™) Keyboard Retraining Program, an innovative and effective program designed to address RSI problems associated with improper use of the computer keyboard and mouse. To date, this keyboard retraining program has helped over 1,000 patients in the clinic setting as well as on-site at companies throughout Silicon Valley. Dr. Kahan’s office is located at 10430 S. DeAnza Blvd., Cupertino, California, 95014.