A cognitive intervention for wrist pain

post by rmoehn · 2019-03-17T05:26:58.910Z · score: 24 (13 votes) · LW · GW · 20 comments

Contents

  Intention
  The intervention
  Evidence
    Situation and severity of symptoms
    The cure
    What happened since
20 comments

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 [LW · GW] and ChristianKl [LW · GW] 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’ [LW · GW] 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.

20 comments

Comments sorted by top scores.

comment by mingyuan · 2019-03-15T22:12:52.925Z · score: 10 (3 votes) · LW · GW

Hm, I’ve read Sarno, but given your framing on his work - do you think this model predicts that general-purpose stress reduction techniques such as mindfulness meditation should alleviate RSI (and other chronic pain)? I’d be interested to see if there’s any research on that.

Also thanks for the data point, you’re the second rationalist I know who has publicly said they’ve overcome their pain with Sarno or Sarno-like methods. I notice that I am confused....

comment by rmoehn · 2019-03-16T02:02:44.712Z · score: 1 (1 votes) · LW · GW

The assumption is that stress can cause pain (by whatever mechanism). So yes, in the cases where RSI and perhaps other chronic pain is caused by stress, mindfulness meditation should alleviate the pain. I made a note to look into the research. If I get to it, I will post my findings here.

As for anecdotal evidence: I just searched for "chronic pain meditation" and got plenty of results. Also, I'm stressed now and sometimes some pain comes wafting through my wrists and forarms. I apply mindfulness (which I learned in 2016, long after the wrist pain subsided) when I want to fall asleep and at those times my wrists feel great.

As to Sarno, the only thing I confidently take from him is that stress can cause pain (sorry for repeating this often). Probably there's more – Sarno has cured many people – but we'd have to dig through and separate the true stuff from the wacky fluff.

Edit 2019-03-19: I now dimly remember searching my mind for suppressed rage whenever wrist pain increased.

comment by Charlie Steiner · 2019-03-15T20:15:46.610Z · score: 6 (6 votes) · LW · GW

You say " there would be an epidemic of wrist pain at typing-heavy workplaces" as if there isn't a ton of wrist pain at typing-heavy workplaces. And, like, funny how stress is making your wrists hurt rather than your toes or elbows, right?

I think, as one grows old, one gets a better sense that the human body just breaks down sometimes, and doesn't repair itself perfectly. Those horribly injured solders you bring up probably had aches and pains sometimes for the rest of their life that they never really talked about, because other people wouldn't understand. My mom has pain in her left foot sometimes from where she broke it 40 years ago. And eventually, our bodies will just accumulate injuries more and more until we die.

If you have pain that you think is due to wrist inflammation, check out the literature and take action to the degree you can. The mind can control pain quite well, and the human body is tough, but if you do manage to injure yourself you'll regret it.

comment by ChristianKl · 2019-03-15T22:05:06.309Z · score: 4 (2 votes) · LW · GW

While doing pain-control directly isn't a useful long-term strategy that doesn't mean that the same is true for a mind-body approach that goes over how do deal with stress.

I think, as one grows old, one gets a better sense that the human body just breaks down sometimes, and doesn't repair itself perfectly.

And it repairs itself a lot worse when it's highly stressed.

comment by Charlie Steiner · 2019-03-15T22:28:50.898Z · score: 4 (2 votes) · LW · GW

Sure. And my comment is more aimed at the audience than at Richard - I don't know him, and I agree that reducing stress can help, and can help more the more you're stressed. Maybe some parts of his story seem like they could also fit with a story of injury and healing (did you know that wrists feeling strange, swollen or painful at night or after other long periods of stillness can be because of reduced flow of lymph fluid through inflamed wrists?), but they could also fit with his story of stress. I think this is one of those posts that has novelty precisely because the common view is actually right most of the time, and my past self probably needed to take the common view into account more.

comment by ChristianKl · 2019-03-16T09:24:29.852Z · score: 4 (3 votes) · LW · GW

It's not either-or. Stress makes the area more tense (both fascia and muscle), and then among other effects lymph fluid doesn't flow as well which makes it harder with the body to deal with existing inflammation.

In general dualism is not a useful framework for understanding humans.

comment by rmoehn · 2019-03-16T03:26:39.270Z · score: 1 (1 votes) · LW · GW

Just to clarify: My wrists were never swollen. And they felt cold.

The common view – I know that it is right most of the time. In this case it could be part of the problem. I made another note to look into how the occurrence of wrist pain issues and the reporting about them developed in time and space. Probably I won't get to all of this, but better have a note than not.

comment by rmoehn · 2019-03-16T03:19:54.736Z · score: 1 (1 votes) · LW · GW

I don't understand the first sentence. Typo?

And it repairs itself a lot worse when it's highly stressed.

Do you mean psychological or physical stress?

comment by ChristianKl · 2019-03-16T09:01:41.320Z · score: 3 (2 votes) · LW · GW

I corrected the first sentence.

The sentence is true for both.

comment by rmoehn · 2019-03-19T05:32:39.309Z · score: 1 (1 votes) · LW · GW

I still don't understand the first sentence.

If psychological stress slows down healing, that would feed into the vicious cycle as well: small injury → pain → stress → injury doesn't heal as well and gets worse → more pain.

comment by ChristianKl · 2019-03-19T15:20:34.905Z · score: 2 (1 votes) · LW · GW

It can happen in that direction, but it's a very simplified model.

comment by rmoehn · 2019-03-16T03:18:24.414Z · score: 2 (2 votes) · LW · GW

If you have pain that you think is due to wrist inflammation, check out the literature and take action to the degree you can.

The problem with this is that checking the literature on page 1 of Google makes the problem much worse for people like me. Every article about ergonomics, RSI etc. should have a caveat: If your thoughts follow this pattern xyz, don't read the horror stories and fix your thoughts instead.

Here's another proposal (aka Richard Diagnoses Your Chronic Pain): Get yourself some legit strain from heavy physical work, then compare the sensation with your wrist pain. Is the wrist pain similar? Then it might be purely physical. If not, not.

For example, when I swing a kettlebell and pull it by extending my wrists, my forearm muscles have to generate more force than is good for forearm muscles. They get tight and pull on my elbow joint. Now when I flex my elbow, it hurts. This pain is different from my wrist pain. It's synchronous with the flexing motion. It comes predictably after swinging the kettlebell with bad form. It goes away predictably when I smash my forearms in order to clear the muscle tightness. The wrist pain in contrast comes and goes seemingly randomly. Sometimes it's the right wrist, sometimes the left, sometimes both. Sometimes it reaches up my forearms, sometimes down my hand. (I'm writing in the present tense. These days I have occasional mild pain. In 2014 it was much worse.)

Oh, and my left wrist is unhappy, because I sometimes get wrist locked during BJJ sparring. This pain is also different.

comment by rmoehn · 2019-03-16T02:55:30.051Z · score: 1 (1 votes) · LW · GW

Charlie Steiner, your comment misquotes me.

If there was great productivity loss because of wrist pain, an economically oriented outlet such as the Wall Street Journal should report on it, shouldn't it? Except in sports, I find it mentioned in a few articles, okay. I made another note to look for statistics.

Here's a prediction that follows from my proposal. If stress causes wrist pain and people stress out, because they think that typing is bad for them, wrist pain should be "contagious". Take an office full of workers who are doing fine. Then one starts having wrist pain for whatever reason, finds online warnings about RSI, tells their colleagues, they get worried about their work being harmful for them, and some of them also start having wrist pain.

I asked my wife this morning if she has heard of anyone having wrist pain. She works in a company of 200 people, in a typical Japanese open plan office with the same small desks and mediocre chairs for everyone. And they're typing a lot on bulky laptop computers. She hasn't heard of anyone having wrist pain.

Why does stress make my wrists hurt rather than my toes or elbows? I don't know. Speculating and summarizing research about that would be another article. Why do people get psychosomatic chest pain and start worrying about it and that makes it worse? I don't think it is, but it could be a selection effect: if my toe randomly starts hurting a little, I don't worry about it, I don't get more stressed, I don't get more pain. It's different with the wrist.

comment by mingyuan · 2019-03-17T05:44:37.655Z · score: 4 (3 votes) · LW · GW

I don’t want to come off as attacking you, but I wonder about the validity of your wife’s evidence. From what I understand Japanese culture strongly discourages any discussion of personal weakness, so it seems likely that the fact that your wife hasn’t heard of anyone experiencing wrist pain doesn’t tell us much about whether they’re experiencing it or not.

comment by rmoehn · 2019-03-19T05:44:11.922Z · score: 2 (2 votes) · LW · GW

You're welcome to attack my reasoning.

I asked my wife about the hiding of personal weakness and whether someone who has wrist pain would talk about it. She said that the hiding thing is more like: ‘You ask me to help you with something. I'm busy or in pain or whatever, but I can't reject a request, so I have to hide my issue.’ She says that at her workplace people talk openly about pain and if someone had wrist pain, they would wonder about it and ask their colleagues.

Of course, a samurai would never show personal weakness. ;-)

comment by ChristianKl · 2019-03-16T09:19:47.676Z · score: 4 (3 votes) · LW · GW

Quick Googling suggests:

Carpal Tunnel Syndrome is the #1 reported medical problem, accounting for about 50% of all work-related injuries
Presently, the costs to businesses that employ workers at high risk to develop Carpal Tunnel Syndrome and other Repetitive Stress Injuries is staggering. It is estimated that RSI "costs employers over $80 billion yearly."
comment by rmoehn · 2019-03-19T05:38:44.383Z · score: 1 (1 votes) · LW · GW

Thanks for calling me out on that. I added a paragraph about statistics.

By the way, if the cost was $80 billion and suppose the percentage of cases like mine was 10 %, that would be $8 billion caused by the common advice that doesn't take into account cases like mine. What are the actual numbers and how much does the common advice decrease cost vs increase it?

comment by ekr · 2019-03-16T13:38:18.908Z · score: 5 (3 votes) · LW · GW

I recommend the book "Why Zebras Don't Get Ulcers" by neuroendocrinologist Robert Sapolsky, in which the exact mechanisms of the stress-response are being described, alongside with a long numbers of experiments and a huge body of evidence pointing towards how harmful chronic stress really is, how it is at the root of an astounding number of pathologies from the metabolic syndrome, ulcers, gastritis, to cardiovascular diseases, to autoimmune diseases, to mental illnesses like depression.

The recurring theme of the book is how the stress response is adaptive in the acute, short term form, but becomes maladaptive in the chronic from (particularly through elevated levels of glucocorticoids).

So, what you describe fits quite well with my own experiences.

comment by rmoehn · 2019-03-19T06:43:17.301Z · score: 1 (1 votes) · LW · GW

Thanks! Maybe I can reduce my stress by referring people to the book instead of writing a series of articles. ;-)

comment by rmoehn · 2019-03-16T22:46:01.192Z · score: 1 (1 votes) · LW · GW

Thanks for all the comments so far. -Tomorrow-On Tuesday I will make some corrections and add a paragraph to clarify my intentions. … Done. Search for "Added" and "Edit".