# 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](https://en.wikipedia.org/wiki/Chest_pain#Psychological) when they're
> anxious. There is a whole [branch of
> medicine](https://en.wikipedia.org/wiki/Psychosomatic_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](http://jockopodcast.com/2017/02/22/63-through-the-valley-my-captivity-in-vietnam-with-colonel-william-reeder-us-army-pilot-vietnam-pow/)
> 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](https://www.lesswrong.com/posts/gEKsuJjnPkzovYBvm/a-cognitive-intervention-for-wrist-pain#LLHs9i2cFcrwL5xk5)
and
[ChristianKl](https://www.lesswrong.com/posts/gEKsuJjnPkzovYBvm/a-cognitive-intervention-for-wrist-pain#kFcS9TsshenY6jCzX)
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](https://wwwn.cdc.gov/Niosh-whc/chart/ohs-cts/illness?OU=CTSWKRL1_R&T=O&V=R2).
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.

Added 2019-08-17: Nate Soares' [Dark Arts of Rationality](http://mindingourway.com/dark-arts-of-rationality/) allow you to put the assumptions in your head while otherwise staying rational.

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](https://www.harpercollins.com/9780380810338/feeling-good/)
[your](http://jockopodcast.com/) [thoughts](https://wakingup.com/). [Address
the](https://echelonfront.com/extreme-ownership/) [root
cause](https://www.manager-tools.com/).

Note that by the stress-can-cause-pain assumption, ‘typing with bad ergonomics
causes injury’ and [‘the human body is a very delicate
machine’](https://www.lesswrong.com/posts/ZB7Hez6bJiZvCAAA2/theories-of-pain)
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](https://web.eecs.umich.edu/~cscott/rsi.html): ‘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](https://youtu.be/8SkdfdXWYaI?t=1036).

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](https://www.grandcentralpublishing.com/titles/john-e-sarno/the-mindbody-prescription/9780759521896/).
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](https://www.harpercollins.com/9780380810338/feeling-good/) 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](https://forum.effectivealtruism.org/posts/yNn2o3kEhixZHkRga/certificates-of-impact)
RichardMoehn-2, which is now owned by Richard Möhn.