Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: TUESDAY, March 14, 1995 TAG: 9503140097
SECTION: EXTRA PAGE: 1 EDITION: METRO
SOURCE: PATRICIA ANSTETT KNIGHT-RIDDER/TRIBUNE
DATELINE: ST. LOUIS, MO. LENGTH: Long
Over 20 years, Donna Abram tried various treatments for carpal tunnel syndrome, from wearing hand splints at night to shots of cortisone.
None worked for long. The tingling, numbness and pain would reappear, until finally, late last year, ``my arm was constantly numb,'' says Abram, 43, coordinator of a vocational rehabilitation program. Surgery seemed unavoidable.
A medical team at Washington University School of Medicine here recommended sticking with a more conservative approach. Simpler measures like good posture and hand exercises work better than surgery, they argued last year in the Journal of Hand Surgery.
Their paper created one of the biggest controversies in the field, at a time carpal tunnel surgery has become the leading type of hand surgery in America. Some 200,000 procedures are done annually.
Today, a few months after treatment, nearly all of Abram's symptoms from carpal tunnel and other problems are gone.
``We're not saying we've got the answer to this, or that surgery is all bad,'' says Dr. Susan Mackinnon. ``I'm a surgeon. I operate all the time. But when you operate on a patient, you want their expectations to be appropriate. The good news - and bad news - is you can take control of this yourself. Surgery often is not necessary.''
There's so much debate in the field, experts can't even agree what to call it. Many doctors call it cumulative trauma disorder, or CTD, but it's just as often called repetitive stress injury, or RSI. Both are broad categories - like heart disease or cancer - that encompass nerve problems and muscle imbalances caused by repetitive motions, bad posture, poor sleep positions and other practices.
Once the domain of musicians, meat cutters and assembly-line workers, CTD has spread into the ranks of secretaries, writers and other computer keyboard users to become the fastest-growing cause of occupational injury in the nation.
It's costing American industry at least $20 billion a year, and the problem is expected to worsen. By the year 2000, 75 percent of American workers may be using computers, according to some estimates.
The growing numbers and soaring medical bills have stirred controversy over what works, whether the problems are real or imagined, and what workplace regulations, if any, are needed.
In April, new guidelines will be announced to help employers recognize hazardous conditions, design correct work stations and develop injury-prevention and treatment plans for workers. The standards are voluntary but the nonprofit group developing them - the American National Standards Institute - is a long-established leader in setting industrial standards.
For some, the guidelines will be overwhelming, says the University of Michigan expert who heads the committee that has developed the standards.
``People want easy answers, like which tool to buy and where do you set the height of this workbench,'' says Thomas Armstrong, a professor of occupation health and industrial operations engineering at the University of Michigan.
There's wide agreement about the value of simple, cheap measures like butcher-knife handles shaped like pistols for meat cutters, wrist rests and lowered keyboard platforms for computer users, headsets for frequent telephone users and footrests and document-holders for desk jobs.
There's less certainty about other, unproven equipment, such as redesigned computer keyboards and armrests that attach to desktops, or even practices such as wearing wrist splints while working.
``There's an amazing array of gadgets and what-nots that people say are ergonomic and they are not,'' says Timothy Springer, professor and chairman of the Department of Human Environment and Design at Michigan State University.
It's even hard to predict who's most likely to develop a problem, Springer says. ``We can have two people do the same job with the same tools, and one develops cumulative trauma disorder and one doesn't,'' says Springer.
You're a more likely candidate if you slouch in your chair while typing, cradle a telephone on your neck, furiously pound your keyboard, reach a lot to perform a job, and sit for hours at a time without stretching, experts say.
You're also a greater risk if you smoke, use oral contraceptives, are a woman (it's unclear why), have a sudden weight gain or become pregnant. In fact, pregnancy may cause carpal tunnel syndrome in one in 10 women, due to fluid buildup.
Large-breasted women also may develop posture problems from years of sitting slouched over to reduce their profile. For them, Mackinnon recommends sports bras or even breast reduction.
Sometimes diabetes, arthritis and other diseases may cause similar symptoms, which is why it's important to see a physician to pinpoint what's causing a problem.
Injuries take years to develop. Symptoms typically don't surface until a person reaches 40 or 50, though there's concern that people may develop the problem when younger because of early computer use.
The signs vary. People with carpal tunnel syndrome usually feel numbness or tingling in the thumb, index and middle fingers, as well as in part of the ring finger, and on the palm side of the hand, Mackinnon says. It's caused by pressure on the median nerve that threads through the bony structure called the carpal tunnel, inside the wrist.
Numbness and tingling in the ring and baby fingers often suggest problems in the ulnar nerve, which runs inside the arm, behind the elbow, she says.
Pain on the top of the hand suggests a problem in the radial nerve that spirals through the forearm. Tension headaches, chest pain and shoulder aches are associated more with a condition known as thoracic outlet syndrome, she says.
With carpal tunnel syndrome, initial symptoms may be associated with a particular task but they often go away at home, says Dr. Mark Koniuch, an orthopedic hand surgeon at Henry Ford Hospital, Detroit. As the problem increases, a person may experience hand pain or numbness at night and, eventually, with most activities.
Sometimes, a precise diagnosis is difficult because there may be overlapping problems. Physical therapist Christine Novak, of Washington University, compares it to a lightbulb that doesn't work: ``The problem could be the lightbulb, the lamp, the cord, the outlet or the fuse box. You don't know where along that line the problem is. All you see is it doesn't work.''
A few simple tests often can help diagnose a problem and suggest a treatment.
Mackinnon and Novak ask patients to hold their hands over their head for 15 seconds to see if they feel tingling. Or they bend a patient's arm at the elbow and pinch the nerve underneath to see if it causes shooting pain.
Then they take a device with two prongs to scratch a person's fingertips. If a patient can distinguish whether the doctor is using one prong or two, his or her symptoms usually are not severe enough to need surgery, Mackinnon and Novak say.
Another indicator of when a patient needs surgery is how long symptoms have been present, or whether they have responded to physical therapy, says Dr. Robert Swartz, an orthopedic surgeon with Rockville Orthopedic Associates in Vernon, Conn.
He concluded from a study that most patients who undergo carpal tunnel surgery benefit from the operation. While symptoms may disappear quickly, it may take several months to regain hand function, he says.
About half his patients can alleviate symptoms with exercises, night splints or a single injection of steroids, he says.
Increasingly, doctors urge caution about splints and particularly warn against wearing them during the day. Too often, the devices cock the wrist in an awkward position that increases nerve pressure.
Surgery still has its place, and it's now done so often, there are very few complications, say Joseph Failla and Mark Koniuch, orthopedic hand surgeons at Detroit's Henry Ford Hospital.
``If therapy alone could effectively treat severe carpal tunnel syndrome, you'd see a lot more patients doing better,'' Failla says.
Still, Koniuch says, ``For most cases of carpal tunnel syndrome, surgery is not necessary.''
Mackinnon says there's one good place to start that can make a major difference: Sit up straight. ``Do exactly what your mother told you to do. You probably can make more of a change doing that than anything else.''
by CNB