NonSurgical Treatment Options for Upper Extremity Overuse Injuries

Richard N. Norris, M.D. December 1994 - August 1995

This multi-part article will discuss the nonsurgical treatment options of (relative) rest, medications, injections, thermotherapy, electrical stimulation, massage, therapeutic exercise, returning to work after injury ("work hardening"), modification of posture and technique, "feedback" techniques, orthotics, splints, and assistive devices for daily activities.

Read parts 1 and 2 about NonSurgical Treatment Options for Upper Extremity Overuse Injuries

Part 3

Reprinted From The RSI Network - Issue 23 - Jun'95

Work hardening: The treatment of injury really has two distinct, although overlapping, phases. Reducing pain or symptoms represents only the first stage. If the person has had to stop or significantly reduce work during the healing phase, a graduated, methodical plan for returning to full work and daily activities is essential to avoiding a relapse. In the field of occupational medicine, this concept is called "work hardening." The worker performs his or her specific tasks, but starts out at a greatly reduced level of time and intensity. The process of gradually building up to normal activity is usually guided or supervised by a physical or occupational therapist.

Ideally, the treating physician will devote ample time to counseling the patient in exercising patience, restraint, and good judgment while recovering. When the person is ready to return to work, a detailed "return to work" schedule is reviewed. It's inadequate and inappropriate for a physician to merely advise the patient to "go back little by little." This is too vague and open to misinterpretation. The value of a written schedule is that it minimizes the risk of overdoing things. Patients must be advised to adhere to the schedule even if they feel they can do more. The use of a clock or timer is helpful. The problem is that people often don't feel when they're overdoing it at the time of activity; the pain evolves several hours later.

The schedule, which is divided into work and rest periods, should be modified to suit the individual. Each level represents a unit of time, usually from three to seven days. The worker should be comfortable at a given level before progressing to the next level, like a mountain climber acclimatizing at a given altitude before ascending to the next height. The work periods gradually increase with each level, while the rest periods gradually decrease. However, the work periods shouldn't increase beyond about 50 minutes, and the rest periods shouldn't fall below five or ten minutes. If the injury has been severe, even slower progress than indicated in the given schedule might be desirable. If pain reappears after progressing to the next level, the person should drop back one or two levels until the symptoms subside. It may even be necessary to stop for a day or two before resuming work.

Setbacks are to be expected. Three steps forward and one back is not unusual, given the attempt to balance not increasing too quickly with not going too slowly. Following a graduated program minimizes the risk of overdoing it: if the load is too much, it will be only a little too much; the setback will be small and recovery swift.

Modification of posture and technique: The physician and therapist must evaluate the role that posture, body mechanics, and faulty technique play in causing and perpetuating an injury, by looking for unphysiological positions or postures or excessive muscular tension. A chief offender is ulnar deviation of the wrists and excessive wrist flexion or extension. If physical/emotional tension is deemed a significant factor, a stress management program that includes biofeedback training might be advisable. Biofeedback can be used for muscle relaxation in general, and specifically while playing an instrument or working at the computer. The patient can learn to relax the specific muscle groups that may be overworking or to engage those muscle groups that are not.

Part 4

Reprinted From The RSI Network - Issue 24 - Aug'95

Feedback techniques: Biofeedback and a stress management program can be extremely useful in treating upper extremity disorders, helping to decrease stress and muscle tension. Some common technical errors RSI sufferers make include the use of too much force in striking computer or piano keys, gripping pens, and pressing on strings. Using biofeedback for specific muscle groups can give valuable information about the level of muscle activity in performing a given task.

The feedback may be an audio signal or visual display (showing the data on a video monitor during the activity). An audio signal is appropriate for typists, whereas a visual display is preferred for musicians. In either case, videotaping the activity may be quite useful, allowing patients more insight into technical errors. Locating the video monitor in front of the patient and the camera to the side or rear allows them to see their posture from various angles while playing or working. This can be done in conjunction with a physical or postural therapist, with the session recorded for later analysis. Videotaping also allows rapid hand and finger movements to be played back in slow motion to assess errors that might otherwise be difficult to spot.

Orthotics: An orthotic is a medical device, such as a splint or strap applied to or around a bodily segment, that's used in the care of physical impairment or disability. Orthotics can be applied to the upper extremity in the form of a splint, or they can be applied to an instrument to help stabilize it and to lessen the amount of force required to control it.

Splints must be chosen appropriately according to the diagnosis and situation. If the chief complaint is night pain from clenching the fists during sleep, a full-length resting splint is indicated. The full-length splint may also be necessary when the chief complaint is pain with daily activities, as the patient must prevent use of the injured hand. This would be particularly true if the dominant limb is injured, since that limb tends to be used rather automatically. Care must be taken not to provoke injury in the opposite arm by the added, unaccustomed use of that side. Removing the splint several times a day to perform gentle movements and muscle contractions will prevent stiffness and soreness of the splinted part. Splints that are custom-molded by an occupational therapist will provide maximum comfort and optimal fit. Slings should be avoided, if possible, as there may be some risk of ulnar nerve compression from prolonged elbow flexion.

For disorders affecting the thumb region, such as deQuervains' tendinitis or CMC arthritis, a thumb spica splint is indicated. However, the spica still allows use of the hand and the patient may still continue to aggravate the injury through isometric contraction of the affected area. If a splint can't be tolerated, a padded fiberglass cast can be used for a week or two, but will cause more stiffness than a removable splint. Both the splint and the cast should be "bubbled out" or relieved directly over the radial styloid to avoid direct, mechanical irritation of the tendons. In addition, the thumb must be aligned with the edge of the forearm, in slight ulnar deviation, so that the thumb extensor tendons are placed in the position of least tension.

Assistive devices for activities of daily living: One of the most commonly overlooked reasons for treatment failure in what might appear to be an adequate therapy program is the effect of activities of daily living (ADLs). When patients complain that pain accompanies ordinary activities such as brushing hair or teeth and opening doorknobs, ADLs must be evaluated and modified. Many adaptive devices have been developed for people with limited hand function or painful hands. These items, which are relatively inexpensive and are listed in catalogs provided free of charge by the manufacturer, include built-up foam handles for eating utensils, writing utensils, hairbrushes, and razors. Levers can be attached to doorknobs to ease opening. Jar wrenches remove lids without force; keyholders eliminate the strain of pinching the key between the thumb and index finger while turning the lock. These devices should be used primarily during the acute phase of injury to minimize physical stress on the tissues. The patient should be weaned from them as soon as tolerated, to prevent tissue fragility.

Driving can be very hard on the upper extremities, particularly without power steering or automatic transmission, and must be minimized during recuperation. Patients must be cautious with any extracurricular activities that involve repetitive motions. Meticulous attention to minimizing or eliminating the stress of daily activities on the hands and arms can make the difference between success and failure.

About the Author

Richard N. Norris, M.D, physiatrist; Director of the Center for Repetitive Motion Disorders, National Rehabilitation Hospital Outpatient Centers at Bethesda; Chair of the American Academy of Physical Medicine and Rehabilitation's Arts Medicine SIG; member of the Board of the Performing Arts Medicine Association.