Interview with Robert Markison
subject: hand advice
March 12, 1997

r is robert markison, the loquatious doctor.

j is me, justin, sufferer of hand woe and faithful student to many.

j - larger, larger scene, what would you say. because i think, you know, get at least a couple hundred people reading this and a lot of them, either, if they're not in the bay area, are those people who are chained to their computers. whether by hobby or by profession. what do we say to them tomorrow if they don't have voice recognition and they don't have all these things, what do we say.

r - we say that they're going to have to work on fitness to become and stay small muscle athletes cause that's how we define them,

j - small muscle athletes

r - they are small muscled athletes. that means a perfect diet, that means shedding stress, that means avoiding bad company, that means staying moist and well hydrated, means keeping your hands warm, avoiding badness, things like alcohol, nicotine, caffeine and all of these things that will derail you in terms of the psyche and/or injury the body and diminish your capacity for repetitive work. get plenty of rest, you know, some aerobic fitness program which would be a swim or a walk, should not be weight lifting, should not be forward limb posture pressures and yoga, could be thi-chi, could be qi quong

j - wait, could be yoga or you're including yoga

r - should not be yoga with forward posturing. if it's yoga don't put forward posture or pressure on the limbs. don't balance yourself against the extended wrist or anything like that. as far as... my other advice is so obvious, it's self-tending, self maintanence because you're on your own as far as if you've got a job that's unyielding, certain physical constraints or what you have to do it, and you can't move to management, you can't move to less hands-on

markison's reach j - or dictation or something

r - dictation. maybe you focus on you.

j - what you're saying is more of a health. it's not straighten up your back and get a better chair with more

r - that helps, all the ergononics requirements that are time-tested help - a good chair, never having a head forward or limb-forward posture if you can avoid it. see that box of stuff in front of you called the computer coming towards you, you don't want to go towards it. everything comes towards you, like sitting up straight and properly and your limbs are hanging at their sides, forearms are parallel to the group so you don't have any undue palm-down or pronated posture then you bring stuff to you, that's the basically the premise of feldencris and other and alexander technique - bring great things to you. i mean, you can tell you're in trouble at home if you bend down to drink a glass of water, and you bend over your plate, if you go to things - things come to you. so the extent to which things can come to you as you're sitting upright breathing well, warm hands, well-hydrated,

j - prepared

r - but when you go to things, you're in trouble cause you're just going to lose power

j - that's a great conceptual model

r - yeah, you're gonna lose power, endurance, if you go to things. things come to you, very important. that's important but as far as breaks, you need to take breaks, that's all, it doesn't mean you speed up to go manic phase and then take a break and shut down. you just take breaks. if you have a sit/stand work station so much the better. we're not on earth to sit really

j - yeah

r - we're on earth to walk around and then lie down at the end of the day

j - you know, since i developed my problems with my wrists with regard to computers, i find myself annoyed with even reading books, i mean having to hold books open and sit down or stand up, and i don't know. i've gotten book holders and i find myself moving around every few minutes, i get very restless

r - you sure, you have a book holder, you have a magic arm, you know, things to hold things. if you just walk next door with me, so for example, you already saw this stuff, but you know, i don't have a chair here, i have one of these things where it's, i'm rocking, its an ab and back machine

j - its an ab and back machine. yeah, this is wild. would you recommend this for people to get?

markison side view r - yeah, fine, why not? what would it hurt? they don't have to, but it just depends, you know. they've got a chance to move around and they're fine and i'm rocking back and forth and i can just sit here and have my little headphone on and talk for a while and just breathe and relax and you know, enter some stuff here's, you know book chapter i'm working on and so i just enter, voice enter an outline and then go with text and just relax... and not look at it, not look at the thing. and then as far as holders for various things, this is called the magic arm, vogen makes it, you know and this can put anything anywhere so, if for example i was reading at home or if i wanted to use a mouse and i wanted to tilt it like this so i'm not down like this, i can just go like this and then let it fall, and i just tapped in a screw, camera mounting into some acrylic that i put together you know and a mirror face on it that i could check my own posture with it. but you know these things you'll find in an industrial lighting supply store, photographic camera store

j - the magic arm, you mean

r - the magic arm, yeah. so if i were reading at home for example, i would just have a magic arm, if i were painting or something or i'd just had that, and that's fine so you can put whatever you want on the end of it. or put them in series so if you got more universal joints you can move stuff around

j - yeah! see, i started conceptualizing when i get out of college i want to get some kind of studio and construct some kind of work-space that would involve foot pedals and lots of universal joints to be able to pull things around and pulleys since i have things

r - right, just bring the world to you whatever it is, but have an environment where you can move around, you can shift, you can sit, you can stand, you can be semi reclined, you know, you could be like in a pod, you know, like some animals will recline in a tree, tree branch, that's sort of hollowed out, you know, there's a lot to these postures that you see in nature, especially the rainforest where the animals are semi-reclining in that sort of way

j - yeah

r - but sitting is very artificial and very bad for you cause sooner or later you're going to be in a head-forward, limb-forward posture to get on to some object that's not healthy

j - well, that's what, i can't, as bad as sitting is, sitting in a bad chair is even worse so, yeah,

r - ergonomic things that are tried and true, the chair and the keyboard tray, some other support on a universal set of joints for the mouse or the cursor input device, foot mouse and so on, that makes a difference

j - now i guess you've already run over some of the diet tips, with regards to

r - well, we skipped one, rsi with stress, yes, its true becasue you see what happens with rsi and stress in particular is humans get into a fight or flight response which physciologically is defined as sending blood towards the brain, towards the guts, lower limbs to get ready to flee the frightening stimulus, fight or flight and so you do it at the expense of the upper limbs. there's so much blood in the body at any time, it shrinks blood supply away from the upper limbs that are already strained from computing during a stress state and then you're trying to make things work and endure with a low blood flow state. so stress means shut down the blood flow of the upper limbs, means more pain with muscle tendon strain and other strain

j - fight or flight, sends blood to the legs

r - fight or flight, yeah. the fight or flight response means the organism is galvanizing to either stay and fight with something or flee it, fly away

j - yeah, sure

r - and so you're going to supply your wit, your brain, your sense of, your heart and lungs, you're going to shun it away from your gut, mostly to go down into the lower limbs cause you're gonna run. this is a saber-toothed tiger at the door of the cave metaphor and that doesn't do anything for your hands, your hands will chill out, its like stage fright where musicians have ice-cold hands. worse yet, environmental changes like working under an airconditioning vent and /or any office that's computer intensive will be a cold environment. so the warm-blooded primate gets colder hands almost like frostbite except this is stressbite and cold exposure in a cold computer room, it's only cold to protect the motherboard, at the expense of the warm-blooded primate, you see, so we've got a mismatch of enviroment and end user

j - so you're saying warm hands is one critical...

r - got to, cause warm hands means blood flow and blood flow means vitality and endurance whether its the heart with the coronary, the brain with neck muscles the hands with macro and micro-circulation. you've got to wash in plenty of oxygen and nutrients and you've go to wash out plenty of waste.

j - sure

r - low flow state will not serve well and stress means a low blood flow state means proneness to injury and sustained injury

markison and justin j - now since this has happened i've had, my sister is really into vitamins and stuff and she's prescibed me B-6 and glucosamine sulfate and bromaline or something like that. i mean, are any of those helpful?

r - they could be helpful, sometimes for bone and joint aches and ligament pains

j - but is that what i have, is that what most people have?

r - no. you have combinations of things

j - inflammation, right?

r - that's right but you're ramping up on nutrients that you may or may not have gotten in an ordinary diet as long as you don't take more than a hundred milligrams of B-6 a day, and as long as you don't take more than 500 miligrams three times a day of glucosamine, and as long as you don't overdo it with vitamins, you're ok. the vitamin i like is nature plus, source of life, one to three a day, tending towards one in the summer and two or three in the winter but everybody's different. again, living a vegetarian life is very easy for me to look at the world of nutrients and pick and choose and know what's really needed and not to overdo it

j - what about anti-inflammatories?

r - i think they're over-prescribed and overused and the hidden problems are liver and kidney problems, the more obvious problems are stomach problems and they're just going to cover up immflamation, not really good for you and unfortunately the knee-jerk response of many practicioners who treat repetitive strain injury is to splint and drug the patient 'til they go away

j - the patients or the problems right? so what about arnica?

r - it can be helpful as a topical anti-inflammatory

j - yeah, that's one thing that i found great, cause i never use advil ever, but i use arnica all the time

r - can be helpful. absolutely, worthwhile. ok so "you're trained as a western doctor alternative medicines or treatments

j - well that's what i've asked, just some of the vitamins, arnica, stuff like that

r - that's it, that's it, ok so you've run into people

j - i've asked about this, we've covered this

r - i don't say there's no place for steroid injections and i don't feel there's no place for surgery, but, i operate on a small fraction of patients with repetitive strain or cumulative trauma and it's gone. as far as a national listing [of hand doctors]? no, we have the american society for surgery in the hands and frankly not all of us are interested in cumulative trauma or repetitive strain.

j - yeah

r - and it is debated, even within the field of upper limb specialists as to whether it exists other than the unhappiness of people who don't like their jobs. i mean in the worst polar biased view on repetative strain is just simply complaining people who are unhappy. and it's all psychological and minimally physical.

j - well, regardless of the problem, right, that's what, that's that key,

r - it's a problem...

j - so how do you answer that

r - it's a problem that won't go away and every cumulative trauma is a psycho physical matter. the psyche lead the person into either the wrong job or just too much of it. and then the physical aspect of it was, are they cut out to do that particular work? and not everybody's cut out to do every job. not coincidental that football players stop when they're 30. there's some things, you just run out of touchdowns, you run out of the keystrokes, you run out of something. that's either ok or not ok depending on how you put bread on the table. but i think some people are geared to doing it long term, as you mentioned art tatum, some people are not. and it's really a matter of how you handle information, and how much brain, how much hand,

j - yeah

r - you dont want to endlessly enslave your hands to activity that's not productive. more brain, less hands, i mean at anything - whether you're a musician or,

j - or very much like you said, haiku, so hm

r - that's right, you express yourself with minimum words

j - it's a question of, so, you know, i have friends, they all say, 'oh, my arms hurt', you know they're working, i tell them 'ok, take breaks, you gotta take breaks, you gotta change your behavior' - now, but is that, when you're working on the computer and your hands begin to hurt, what do you do then? is that the time to go see a doctor, is that the time to..?

r - no, no, unless its a lingering problem where it doesn't go away overnight, and doesn't go away over a weekend then you might see someone. taking breaks is sage advice, staying very moist, well-hydrated so at least you take pee breaks is very important... and shedding stress, learning how to breathe, learning some form of medication that can be on the spot - just right there do it - close your eyes, take a few deep breaths, imagery of warming your hands so they're fit to work, unraveling muscular tension between neck and fingertips, understanding how much the keyboard stuff is necessary and how much it is not. cultivating ambidexterity for use of perimeter keys, being able to get alternative devices like the split keyboard or perhaps the foot mouse, whatever. whatever you can do to offload upper limbs and not enslave them, again repeating some of the things we've already said, but just think if you're still intense that you're way forward with head and limb that you're going to start to crush nerves and vessels and above and below the collarbone and if you start to do that, by head and limb forward postures, in the name of getting toward the box, and the keyboard, and the mouse, then you're in trouble

j - but when are you doing permanent damage? is that an issue?

r - it may be an issue and its just a question of how long symptoms linger. if they linger more than overnight, and it's night after night after night, then you may be doing some damage, but the problem is, on a scientific level, its not quantifiable, you can't go in and take tissue, run it under a microscope and see obvious inflammation. when you take tissue out of these limbs, it generally doesn't show anything and so it's hard to know, except for the psycho-physical aspect of being

j - yeah, there's no external signs of this kind of stuff, right?

r - right. there are aches and pains and when aches and pains get to be more than that, and they linger, then you're going to have to fundamentally change your ways and that's very vague and not quantitative. as far as permanent damage, i've now had follow up since 1982 when the IBM PCjr was mass distributed, that was 15 years ago, in '82, so now, 15 years later i've seen people who've made good changes and are doing fine but most of them are not at the pre-injury computing level.

j - oh, i see

r - nor do they seek to be because they see it as the fire and the cause and the injury.

j - i've shifted my behavior enormously since, i've gone, i try, i first, i healed somewhat after i saw you and then i tried to return to that level and that was wrong and i injured myself again and so now what i've done is i've moderated my behavior to shortened sporadic, you know, well breaked, well hydrated use of the computer but it doesn't seem like, i'm not seeing results in weeks, it seems like months or years from now until the pain ....

r - you get RSI and it's foolish to think that six months is going to do it, its more like one to two years like tennis elbow is one, two or three years. if you want to naturally heal tennis elbow in one, two or three years,

j - wow

r - and so most people in this giddy phase of impatience and no weight state with rapid chips don't understand good old patience and good old natural time but its there and it takes a long time

j - but i can't think of what i could do to be creative or to be productive without my upper limbs.

r - right, would that you had asked that question before you go into intensive computing. we don't know what we've lost 'til we're losing it. and so you're in a position where your self-rescue can be a good steady one cause you're a smart guy. people who aren't smart have fewer options and so you really have to take stock of identity, iq, and whole history - you know where you've been, where you are and where you will be

j - but i think i could take up sculpture but i don't know how that would be for my hands or i could take up house...

r - depends on the medium, depends on the medium, if you're doing fine little sculpture and you know, you're working in a warm media where you're not doing cold stuff, throwing it on a potter's wheel. you could do some sculpture, certainly you could

j - so i have to consider, if its not fine motion, right, it's not

r - some of it, it's not going to be relentless fine motion, you can certainly do sculpture with some tools and there are videos on how to use them

j - but gripping a hammer, building a house - that wouldn't be...? i mean all these things, i guess anything in moderation becomes ok?

r - more power tools, yeah more power tools. there's some wonderful power tools out there, i mean .....use a screwdriver

index | on computers/interface issues

markison | hands | body | justin's links