A battle plan for surviving the
repetitive strain wars
By Judy Foreman
04/08/1996

Jeff Del Papa's hands and forearms gave out five years ago, after 15 years of pounding keyboards as a computer programmer for a company in Wilmington.

Today, Del Papa, a 38-year-old Watertown man who once played medieval muscial instruments and opened jars with a flick of the wrist, is back working as a programmer, only now he has to dictate every thought into a voice-activated computer.

It recognizes 50,000 words -- provided Del Papa puts complete pauses between words. . .so . .that. . .he. . .ends. . .up. . . speaking. . .like. . . this. Naturally, this drives anyone within earshot nuts in 15 minutes, he says, and it means his e-mail is about as private as a TV news broadcast.

And while Del Papa's hands no longer ache at the end of the day, his voice sometimes does, "because all of a sudden you're talking all day.''

Beth Baron, too, is a casualty of the repetitive strain wars. Baron, 25, of Somerville, was typing away as a secretary at Children's Hospital two years ago when her forearms suddenly felt too heavy to move and her wrists began to tingle.

Within three weeks, she went "from being totally fine to having to dial the phone with my feet,'' she says. "It hurt to brush my teeth, to wipe my own behind, to do my laundry.''

Del Papa and Baron are among the walking wounded, the 332,000 Americans whose work has left a trail of injured fingers, hands, wrists, forearms, shoulders, necks and backs, according to 1994 Bureau of Labor Statistics.

Their troubles go by many names -- cumulative trauma disorder, work-related musculo-skeletal disorder of the upper extremities, RSI or repetitive strain injury, carpal tunnel syndrome, tendonitis, tension neck syndrome, thoracic outlet syndrome -- even tennis or golf elbow (epicondylitis). Sad to say, you can also get the last two by typing, not just by swatting at balls for fun.

Whatever you call it, the number of people with such injuries today is more than 10 times higher than in 1982, says Dr. Lawrence Fine, director of the division of surveillance, hazard evaluation and field studies at NIOSH, the National Institute for Occupational Safety and Health.

To be sure, many of these cases probably involve just greater recognition and reporting of injuries, says Fine.

But while many doctors, workers and even corporations now take RSI more seriously -- and some companies aggressively adapt work stations to prevent such injuries -- there is still resistance in some quarters to the mere idea that a person can get hurt just by typing or other repetitive work.

This is partly because some RSI diagnoses are based on a doctor's clinical judgment, not objective tests. And partly, because of looseness in the medical definitions themselves.

Last July, for instance, a review article in the Journal of Hand Surgery concluded that not one of 52 relevant studies had established a true cause-and-effect relationship between work and well-defined medical conditions, partly because the criteria for accurate diagnosis are so fuzzy and overlapping.

But others, among them Hilary Marcus, co-program director of the Massachusetts Coalition on New Office Technology, an advocacy group, insist that the increase in RSI cases -- probably spurred by growing computer use at home and at work -- is real.

So is the toll, she says, in both human and economic terms.

At one recent meeting of her group, grad students who had planned on long careers in computers spoke, sometimes tearfully, of injuries that now threaten their dreams and livelihoods.

It costs $17,582 on average for each worker's compensation claim for repetitive trauma disorder, including carpal tunnel syndrome, says Letitia Davis, director of occupational health surveillance at Department of Public Health.

That, not surprisingly, scares the you-know-what out of Congress and Big Business, which have teamed up to stomp out efforts by the Occupational Safety and Health Administration to establish workplace standards to prevent such problems.

Corporate lobbying has been so intense that OSHA can't even get its new standards "out the door,'' says spokeswoman Cheryl Byrne, and won't until "hell freezes over.'' (The good news, is that you can get the standards, which detail methods of prevention and ways to track injuries, through the Internet.)

While injuries vary with the type of motion a worker does -- punching data into a computer is different from stabbing beef 20,000 times a day in a packing house -- the biomechanics are similar.

When you type, for instance, you use muscles that are attached to bones by tendons, which slide around in tubes called synovial sheaths. Repetition of this motion can cause inflammation, says Dr. Rose Goldman, director of occupational and environmental medicine at Cambridge Hospital.

And if inflammation or blocked blood flow occur in a tiny space like the carpal tunnel -- the passage in the wrist made of bones and a ligament through which tendons and a nerve pass -- the result can be nerve compression, which leads to tingling, numbness and pain.

There are two ways to attack this -- by preventing it in the first place or treating it later. Prevention wins hands down.

Sometimes, all that takes is more work breaks. One NIOSH study showed that workers are just as productive and have fewer symptoms if they take a 5-minute break every hour instead of a 15-minute break every few hours.

But prevention usually involves ergononics, too, the science of fitting the workplace to the worker, not vice versa.

For people who bang away at computers all day, this means typing with wrists in "neutral'' position, that is, with your hands neither flexed up nor drooping down, and with wrists not angled either left or right, says Bryan Buchholz , an ergonomist at the University of Massachusetts at Lowell.

Your chair and keyboard height should also be adjusted so you can type with your feet on the floor -- or on a footrest -- with about a 90 degree angle at your knees, hips and elbows. Pull-out keyboard trays and adjustable chairs may help achieve this.

The key "is to keep the keyboard low enough that you can relax your shoulders,'' adds Dr. David Rempel, director of the ergonomics lab at the University of California in San Francisco. And if you talk on the phone while typing a headset is essential, ergonomists say, if you're prone to neck spasms.

Beyond that, though, the gurus disagree.

Fine, for instance, is a firm believer in resting the elbows on padded arm rests to prevent neck spasms while you type.

Dr. Emil Pascarelli, professor of clinical medicine at Columbia University College of Physicians and Surgeons in New York, advises just the opposite. In fact, he says, "You're probably better off not having arm rests. The problem is you can't adjust the height of the arm rests, and if your shoulders are too high you'll get neck and shoulder pain.''

Wrist rests are another bone of contention. Some people swear by them, but Pascarelli says they "transfer all the activity of keystrokes to the much more vulnerable forearm muscles.''

"If you must use a wrist rest,'' adds Rempel, "don't use it while you're typing, but only while you're resting.''

Keyboards, too, are a subject of debate. Some ergonomists advocate flat keyboards, not those that slope up toward the back. Others advocate split keyboards or tent-like keyboards, but these are too new to have been fully evaluated.

Generally, the pros agree that if you use a mouse or other pointing device, you should keep it near the keyboard, not grip it too hard and not "drag'' it too much. But they disagree on whether clickable mice or track balls are easier on the body.

If you think you already have RSI, your best ally may be common sense. With carpal tunnel syndrome, for instance, rest, ice, anti-inflammatory drugs and cortisone shots may help.

Some self-diagnosed sufferers also try wrist splints, which may help. But if you try to type with them on or leave them on too long, you may make things worse, specialists say.

Some people also get relief from massage and acupuncture, but for many, specialist say, physical therapy helps the most.

With physical therapy, the goal is to "teach people how to gently stretch and strengthen'' muscles in the forearm, neck and shoulder blades, says Kathi Fairbend, a Weston therapist.

And if all this fails, surgery may be the answer.

In carpal tunnel surgery, the goal is to "release'' -- that is, slice -- the transverse carpal ligament on the "roof'' of the tunnel so that pressure inside the tunnel is diminished.

This used to mean a two-inch incision from the palm to the wrist, says Dr. W.P. Andrew Lee, a hand surgeon at Massachusetts General Hospital. Recently, doctors have turned to endoscopic surgery, which involves smaller incisions and tiny TV cameras, and Lee and a colleague have now devised an operation to combine the best of these two techniques.

But it makes no sense to go through surgery -- or even less invasive remedies -- then go back to the same old, work station.

Sooner or later, you have to fix your work station so you don't get hurt, which may mean getting political.

At least, that's how Beth Baron sees it. "You have to act up,'' she says."Fight for your health. Fight for your rights.''

SIDEBAR 1

To learn more about RSI

For more information, call:

• The Massachusetts Coalition on New Office Technology, 617-776-2777.
• The Massachusetts Department of Public Health, Occupational Health Surveillance Program, 624-5624.
• The National Institute for Occupational Safety and Health, 1-800-35-NIOSH, or 1-800-356-4674.
• You might also read:
• "Repetitive Strain Injury," by Dr. Emil Pascarelli, published by John Wiley & Sons, Inc., New York.

You can also get information on the Internet at: http://www.princeton.edu/uhs/hi_ergonomics.html

or, for both the OSHA standards and proposed California standards at: http://www.tifaq.com/ergonomics/standards.html

SIDEBAR 2

YOU COULD HAVE RSI IF YOU:

• Do things with your non-dominant hand that used to be easier with your dominant hand (dialing the telephone or punching your codes into the automatic teller machine at the bank with your left hand when you are right-handed, or vice versa).
• Use your forearm, feet, or shoulder, instead of your hand, to push open doors, or find yourself shaking out your hands because they have gone numb.
• Avoid wearing or buying certain kinds of clothing because it is too difficult to put them on.
• Keep dropping things.
• Find you can't peel or chop food.
• Experience trouble tying ties, buttoning collar buttons, hooking bras or putting on jewelry.
• Have problems with keys or brushing teeth.
• Feel overly protective of your hands (won't to shake hands, for instance.).
• Don't hang on to the handrail, subway strap, or bus pole with the hand you usually use.
• Have difficulty holding a book or newspaper.

Source: "Repetitive Strain Injury: A Complete User's Guide" by Emil Pascarelli, MD and Deborah Quilter.

Judy Foreman’s column runs every other week. Past columns are available on www.myhealthsense.com.

 Listen to her live call-in webcast radio show every Wednesday night from 8:30 to 9:30 EST on http://www.healthtalk.com.