Date: Thu, 17 Mar 1994 19:11:59 -0500 From: Monty Solomon Subject: Getting a Grip on Hand Problems From FDA Consumer 7-8/93 Getting a Grip on Hand Problems by Cheryl Platzman Weinstock A trip to the supermarket or signing a paycheck didn't used to rank high on the list of 31-year-old Wanda Wood's concerns. But now, everyday chores like pumping gas and carrying groceries to the car are ordeals for her. Wood can't hold a pen long enough to finish signing her check. She has trouble grasping a nozzle to fill her gasoline tank. And she can't grip her groceries to keep them from falling out of her hands. "It's when a jar of tomato sauce cracks all over the pavement that I get real embarrassed," said Wood, a Richmond, Va., former postal worker. "It's pretty tough to handle when you're standing in a parking lot covered with red goo." Like Wood, an increasing number of American workers are experiencing the sudden onset of one of several cumulative trauma disorders affecting the hands, according to James McGlothlin, Ph.D., a research hygienist at the National Institute for Occupational Safety and Health in Cincinnati. Doctors often call them repetitive strain injuries (RSIs). RSI is a catch-all term used to refer to many painful conditions, such as trigger finger, nerve spasms, and carpal tunnel syndrome. They can cause stiffness, swelling, tingling, weakness, numbness, and, in some cases, irreversible nerve damage. Carpal tunnel syndrome is the most frequently reported RSI, with 192 cases per 100,000 workers in 1989, according to the U.S. Public Health Service. It occurs when tissues on the palm side of the hand swell, compressing or entrapping the important median nerve, which runs through this area. Numbness and tingling usually start in the wrist, and can radiate down to the thumb and fingers, or up to the elbow. Many patients feel pins and needles when their wrist is tapped. Weakness occurs on effort. For example, patients may suddenly drop objects they are holding. A nerve conduction test, a recording of the electrical activity of the hand and arm muscles, is helpful in diagnosing this disorder. Other RSIs include nerve spasm and "trigger finger." When nerve entrapment and the pressure caused by it occurs over a long period, the nerve can become irritated and go into spasms, stimulating muscle activity that eventually causes pain similar to severe muscle cramps. When finger tendons, fibrous bands of tissue that connect muscle to bone, get irritated, they can grow nodules, which, at the points of attachment, get caught in the lubricating sheath that surrounds them. When this happens, the finger can become stuck; this condition is called trigger finger. RSIs are self-limiting conditions that result from excessive use of the muscles and tendons of the hands, wrists and forearms. Meat cutters, auto workers, cashiers, journalists, keyboard operators, and others who spend long hours at repetitive chores are particularly vulnerable. Wood used to spend long shifts operating a letter sorter, typing hours at a time at a computer keyboard to route the mail to its destination. "My pain eventually became so severe that it worked its way from my fingers to my wrist to my elbow until it felt like a constant crook in my neck," she said. Hopes for Help Because the consequences of these disorders are so high, the goal of safety and health professionals across the country is to collect information on which to base decisions about the best ways to prevent and treat these illnesses. But this is not an easy task. For example, some proposed treatments have not been substantiated by controlled clinical trials. According to John Vanderveen, Ph.D., director of the Food and Drug Administration's division of nutrition, "We have from time to time dealt with claims for the use of nutrients to prevent or treat carpal tunnel syndrome, but could only find anecdotal reports." He said, "It's difficult to do such studies because animal models are more tenuous to tease out pain and performance data from than humans. So right now we don't know if basic clinical research is likely to support such claims." In addition to RSIs, various forms of arthritis can cause hand problems. Rheumatoid arthritis, for example, is a chronic, autoimmune disease affecting the entire musculoskeletal system. Osteoarthritis, a degenerative, "wear and tear" condition can also affect the hands. (See "Arthritis: Modern Treatment for that Old Pain in the Joints" in the July-August 1991 FDA Consumer.) Vanderveen said researchers are investigating the innovative use of omega-3 fatty acids, found in fish oils, to help suppress the disease by curtailing production of prostaglandins, a series of hormone-like substances associated with inflammation that occurs in arthritis. Vanderveen cautions that it's still premature at this time to think that these fatty acids will be therapeutic for many arthritis patients. Today the best bet for RSI patients is to cope with the condition in ways similar to patients with arthritis. Such coping skills include protecting and caring for their joints and using OTC drugs such as aspirin or ibuprofen (Advil, Nuprin, Motrin IB) for mild to moderate symptoms or prescription NSAIDs (nonsteroidal anti-inflammatory drugs) for stronger anti-inflammatory relief. A general practitioner can treat these disorders, in most patients, with either exercise, rest, aspirin, or NSAIDs, such as Motrin or Naprosyn. But if relief does not occur within a few weeks, the physician may refer the patient to a specialist. Occupational therapists can also help patients with these disorders to practice "joint protection," according to Jan Chmela, director of Sheltering Arms Day Rehabilitation Program in Richmond, Va. Chmela, herself an occupational therapist, said that patients can learn to use their hands in "non-deforming positions." For example, instead of grabbing a key with a thumb and twisting, patients can learn to turn a key with adaptive equipment. They can learn to use their largest joints for a job, rather than their smaller, more vulnerable ones, for opening a jar, for example. She advocates teaching patients to use their hands closest to their anatomical position, outstretched as much as possible instead of twisting and turning them, because bending the hands stresses the joints. As with most other disorders, however, prevention, where possible, is the best cure. The National Institute for Occupational Safety and Health is focusing research on ways to redesign the workplace to make RSIs less likely. The agency's McGlothlin said, "We don't want to try and fit the worker to the job, but the job to the worker, and that can best be done through engineering controls so that both the worker and the company benefit." For instance, he suggests adjustable-height tables to accommodate workers of different heights and builds. McGlothlin also stressed that employers must be sensitive to the extreme demands on many of their workers and allow for recovery time. "There are more and more demands on people these days. Many work two jobs or through the night. Women in the workplace may also be raising families. Employees need time off to rest. In order for ideas that we've developed to succeed, there has to be a partnership between workers and their companies to make it a more productive and helpful workplace," he said. Employers can also cut down on RSIs by providing their workers with chairs that give them better postural support and adjustable work stations that allow them to adjust their screen, keyboard and wrists. Diagnosis Important Forty-three-year-old Barbara McGhee, a public affairs specialist at a Virginia Department of Health and Human Services Social Security Administration office, was diagnosed with rheumatoid arthritis at age 19. Over the years, her hand joints have become rigid and misshapen by chronic inflammation. Her hand dexterity is poor--just shuffling through the pages of a book is difficult. When McGhee first heard the diagnosis, she said she refused to despair. "I went to the library and learned all I could about it." Because unrealistic expectations only make it that much harder on patients, McGhee said she "needed information so I could make some important decisions. I needed to learn what I would and would not be able to do." "I realized my attribute was my high energy level and if I cultivated it, I could put it to good use." Twenty-four years later, she is unable to waterski or horseback ride or participate in other sports she used to adore, but she has nevertheless found her niche. McGhee not only holds down a full-time job, but also volunteers for her local chapter of the Arthritis Foundation and the Richmond Mayor's Commission for Disabilities. McGhee said she only wishes that she hadn't waited five years from the onset of her problems to seek the help of a physician. She said she wonders if she had paid attention to her condition earlier whether she could have avoided having one wrist and one ankle replaced, and the other ankle fused. Because aches and pains are commonplace, people with early morning stiffness, difficulty in movement, or tenderness in one or more joints sometimes do not realize that they may need to see a doctor. But it's important that people whose symptoms last longer than several weeks see their physician immediately. For example, in some cases of moderate to severe carpal tunnel syndrome, early treatment can prevent significant permanent damage to nerves. Hayes Willis, assistant professor of medicine, division of rheumatology, allergy and immunology at the Medical College of Virginia, explained that, "damaged nerves just don't heal well." He added that for both arthritis and RSIs, the earlier a diagnosis is made, the greater the likelihood of minimizing disability. n Cheryl Platzman Weinstock is a writer in Long Island, N.Y.,who specializes in health and science issues. For More Information For further information about repetitive strain injuries, call the National Institute for Occupational Safety and Health at (800) 356-4674. For information and referral 24 hours a day about arthritis, call the Arthritis Foundation's National Hotline at (800) 283-7800. The hot line can provide local chapter numbers and brochures that address many of the physical, emotional and coping problems that arthritis patients can face. The impact of arthritis on the family, pain management, proper exercise, and up-to-date medication information is available. ####