Richard N. Norris, M.D.
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.
Reprinted From The RSI Network - Issue 21 - Dec'94
First, a note: Repetitive motion disorders can usually be treated nonoperatively with success, especially in their early stages. However, it should be kept in mind that nonsurgical treatment isn't always the conservative path, and there are many conditions that respond quickly and reliably to surgical procedures. In situations of prolonged pain and disability, nonsurgical procedures should not be pursued indefinitely when surgery would correct the situation and allow the patient a rapid return to work or play.
(Relative) rest: Perhaps the most important treatment of all is rest. We all know how difficult it is for professionals to take time off to rest, so we must borrow the concept of "relative rest" from sports medicine. Depending on the severity of the injury, this may mean cutting back, rather than completely stopping, work or (for musicians) performances. Office workers may need to cut down on work hours or space out the typing or writing over the course of the day. For musicians, it may be possible to modify or change the repertoire, such as avoiding piano pieces with large chord spans, broken or serial octaves, or triple forte playing. Relative rest really means avoiding pain-producing activities.
Medications: The most commonly used medications are nonsteroidal anti-inflammatory agents. (Caution must be used in patients with a history of ulcers, bleeding disorders, or hypertension.) They should be taken with meals. In general, anti-inflammatory medications tend to be more useful in acute than in chronic situations, and should probably be used not more than 3 or 4 weeks at a time. They should rarely be used as the sole treatment modality, but may be helpful in conjunction with other modalities and treatment strategies. There is evidence that topically applied salicylate cream (trolamine salicylate) may be effective for localized inflammation. In addition, low doses of antidepressant medication are often helpful as part of the treatment of myofascial pain. Narcotic medications, sedatives, or "muscle relaxants" should be avoided.
Injections: Dry needling or injection with anesthetic alone is routinely used in treating myofascial trigger points. Injections performed with a solution of corticosteroid and anesthetic are commonly used as part of the treatment regimen for de Quervain's disease, sub-deltoid bursitis, trigger finger, and epicondylitis. For median nerve entrapment at the wrist (CTS), it's best to avoid the colloidal steroid preparations and use only the soluble steroids, as colloid solution has been found lying on the median nerve at surgery, possibly causing mechanical irritation. Injection is generally contraindicated for patients with any weakness or thenar atrophy or advanced sensory loss.
Patients with minimal or intermittent symptoms of CTS tend to have the highest success rate. D. P. Green found steroid injections to give good to complete relief of CTS in 81% of patients. In most patients the symptoms recurred from 2 to 4 months after injection. He found a positive response to an injection to be an excellent predictor of a successful surgical procedure. The injection is performed by insertion of a 25-gauge needle proximal to the wrist crease and ulnar to the palmaris longus tendon. This avoids the median nerve and the transverse carpal ligament. The patient can be asked to gently flex the digits a few degrees; if the needle is in contact with the flexor tendons, there will be slight movement of the syringe, assuring proper position before injection. To avoid injecting into a tendon, the injection must not be forced against pressure. If injected proximal to transverse carpal ligament through the investing fascia of the forearm, the solution will easily flow into the tunnel and the area of tenosynovitis.
Reprinted From The RSI Network - Issue 22 - Feb'95)
Thermotherapy: Thermotherapy can take the form of heat or cold. Heat is commonly applied as either a hot pack, which doesn't have much depth penetration, or ultrasound, which has much deeper penetration. Ultrasound can be pulsed or continuous; pulsing helps prevent excessive heat buildup and should be used in bony areas such as hands and wrists. An ultrasound unit with a very small head works better for bony areas. In treating areas of nerve compression, ultrasound should be used only in very low doses (in the range of 0.5 watts/cm2). A normal dose (1.5 to 2.0 watts/cm2) actually has been shown to be deleterious to nerve healing.
Fluidotherapy is a type of thermotherapy using heated, pulverized organic material such as walnut shells or grain husks. Advantages include the ability to attain higher specific heat than with other methods of application, and the opportunity for the therapist to put his or her hands into the fluidotherapy bath to perform joint mobilization or soft-tissue massage concurrently. Although the heat of paraffin baths doesn't penetrate deeply within the tissue, these baths are very good for dry skin and for relaxing contracted areas. If inflammation is present, cold serves as a vasoconstrictor to prevent or reduce swelling. Ice may be applied for 15-20 minutes every hour or two as needed. When applying cold over sensitive, bony areas, it's best to use a gel pack, which remains soft even at freezing temperatures.
Electrical stimulation: The use of electrical stimulation is often beneficial when there is edema or swelling, as the current can help to polarize and drive interstitial edema back into the vascular system. This treatment should be combined with compression and elevation. Electrical stimulation can be used to induce gentle, rhythmic muscle contractions in sore areas, helping to relieve discomfort by removing interstitial edema and increasing blood flow to the muscle. Electrical stimulation can also be used with active muscle contraction to strengthen weak or atrophied muscles. Caution must be used with patients who have pacemakers and those with very sensitive skin, which can be irritated by the electrodes.
Massage: Massage is useful in stimulating blood flow, reducing edema, and breaking up localized areas of muscle spasm or trigger points. It's also helpful for general relaxation and stress reduction.
Therapeutic exercise: Physical exercise plays a vital role in keeping workers and performers fit and healthy. Sitting at a desk or making music, while not athletic in the strict sense of the word, definitely has its physical demands. Therapeutic exercise is useful in both preventing and treating specific ailments. Often, after a period of injury, the muscles in the hand and forearm become weak from disuse or nerve compression. Therapeutic exercise, along with a gradual return to working or playing, is necessary to restore muscle strength and endurance. Working on proximal strength, especially scapular stabilization, is greatly beneficial. Strengthening the wrist and finger extensors, a common area for pain and dysfunction, may be preventative as well as therapeutic. Hand exercises must be undertaken with caution and supervision because of the risk of overdoing the exercises and thereby worsening the condition. One of the chief offenders in causing further injury is therapy putty, which tends to be rather stiff, especially when cold. There are several different colors of putty available in varying degrees of stiffness and resistance. Putty must be used in a graded fashion and prewarmed. Rubber bands and manual resistance may also be used. A well-balanced therapeutic exercise program should address strength, endurance, flexibility, and gracefulness.
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.
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.
Last Updated: 10/21/00