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A PAIN IN THE WRIST A LOOK AT CARPAL TUNNELL SYNDROME, THE DISEASE THAT HAS WORKERS AILING, EMPLOYERS FRETTING, AND DOCTORS BUSY TREATING IT

THE BALTIMORE SUN

IT HAD TO HAPPEN. AN 11-YEAR-OLD GIRL IS SU-ing the Nintendo company because playing Teenage Mutant Ninja Turtles gave her carpal tunnel syndrome.

That's the kind of page 10 story that most newspaper readers file under "whimsy: insignificant." But it's a symptom of a growing national problem.

It's no longer news that carpal tunnel syndrome (CTS), a potentially crippling disorder of the wrists and hands, affects millions of office and factory workers across the country and leaves product manufacturers, employers and insurers vulnerable to billions of dollars in liability and compensation claims. In fact, carpal tunnel syndrome is spreading so rapidly that it may well become in the 1990s what polio was in the 1950s and mononucleosis was in the 1960s: the Disease of the Decade. Today, carpal tunnel syndrome and related disorders account for over half of all work-related illnesses, according to the U.S. Bureau of Labor Statistics, and surgery to correct CTS is the second most frequently performed operation in the United States. Locally, for instance, the seven hand surgeons who make up the Greater Chesapeake Hand Specialists practice in Lutherville are treating between 800 and 1,000 new cases of CTS every year.

The classic symptom of CTS is numbness in the hands and fingers. "People come to us complaining that they can't hold onto anything," says Dr. Michael A. McClinton, a plastic surgeon affiliated with Union Memorial Hospital's Hand Clinic. "They can't grip a tool or a coffee cup, or they can't make their hands do what they want them to. Often they lack normal sensation in their hands, or they feel a numbness and tingling as if they'd had a shot of Novocain." In more severe cases, CTS can cause pain in the hand and wrist or even muscle atrophy in the hand.

CTS is one member of a family of diseases known as cumulative trauma disorders or repetitive stress disorders. All involve damage to nerves, tendons and associated tissues as a result of repeated biomechanical stress. In the case of CTS, compression of the median nerve, which travels down the arm, through the wrist, and into the fingers, leads to pain, numbness, and weakness in the hand.

Anyone can develop CTS, but the people most at risk are those whose jobs or hobbies involve repetitive wrist movements, forceful grasping of tools or other objects, awkward positions of the hand and wrist, direct pressure on the wrist, and use of vibrating hand-held tools. In addition, the disease frequently shows up in people with diabetes and arthritis, and in pregnant women.

Dr. Martin Z. Kanner, a Baltimore physiatrist -- that's a specialist in physical medicine and rehabilitation -- estimates that he sees about four or five new cases of carpal tunnel syndrome every week. The chief of rehabilitation medicine at Baltimore County General Hospital, Dr. Kanner finds the increase in CTS ironic.

"You'd think," he says, "that with the 20th century shift away from physical labor and toward electronics and high technology, we'd be subjecting our bodies to less trauma. But most of today's jobs seem to invite repetitive stress. Certainly there's an abundance of occupational and avocational sources of CTS. I'm seeing patients as diverse as writers, typists and secretaries, computer operators, electronic checkout scanners, assembly-line workers, post office letter sorters, carpenters, clam shuckers, gardeners, knitters and needlecrafters and musicians."

Part of the problem is the anatomy of the carpal tunnel, a narrow passage in the wrist. "There's not a lot of room in there," Dr. Kanner says. Besides the median nerve passing through that space, you also have the tendons that flex the hand and wrist, and the synovium -- the tissue that surrounds the tendons and everything else in the carpal tunnel. The "walls" of the carpal tunnel are formed by a bracelet of bones on the bottom and a tough membrane, the flexor carpal retinaculum -- or the transverse carpal ligament -- on the top. Anything that compromises that space can cause CTS.

Classically, the trauma of repetitive wrist motion causes the synovium to thicken, and the carpal tunnel becomes inflamed. ++ Or arthritis or fractures can change the structure of the bones. Edema, or water retention -- such as occurs in pregnancy -- can cause the soft tissues to swell. In any case, the result is the same; over time, the carpal tunnel space is affected, the median nerve gets compressed, and the patient starts complaining of tingling, numbness or pain.

Some physicians believe that there are two distinct kinds of carpal tunnel syndrome. "The classic case," says Dr. McClinton, "the kind that's been around for years, is a post-menopausal woman who has gradually developed symptoms over a number of years without having suffered any obvious trauma to her wrist."

But in the last 10 years, he says, the disease has proliferated among white-collar professionals, younger people and men. These cases tend to come on more quickly, and they originate in occupational or avocational sources.

Not that repetitive stress disorders are anything new. Bernardino Ramazinni, the Italian physician who is known as the father of occupational medicine, first described them in 1717. In "The Diseases of Workers," Dr. Ramazinni divided occupational diseases into two categories: those caused by exposure to hazardous materials and those caused by "certain violent and irregular motions and unnatural postures of the body [that impair] the natural structure of the vital machine."

In the last century, workers were familiar with conditions known as "telegraph-operator's arm," "bricklayer's shoulder," "stitcher's wrist" and "cotton twister's hand." Shortly before World War II, the U.S. Labor Department's Women's Bureau blamed such repetitive motions as wrapping packages, typing and folding for up to one-third of women's occupational diseases.

What is new today is the spread of repetitive trauma disorders, especially CTS, into the white-collar workplace. U.S. Census data released in March 1991 reveal that 37 percent of all adults now use computers on the job, compared to 25 percent in 1984. The proliferation of computers on the desks of middle and upper-level managers has resulted in a vastly increased pool of people at risk for CTS.

Even among clerical workers, who have always done the bulk of typing and data entry in modern offices, working conditions are changing in ways that increase wrist trauma. Twenty years ago, a typical secretary automatically gave her hands frequent rests as she changed ribbons, erased typos, inserted paper and carbon leaves, manipulated a typewriter platen, and walked around the office to perform routine tasks.

In factories as well the trend in the last 100 years has been toward breaking tasks down into smaller units that can be measured and monitored. Today, there are few craftsmen creating -- say -- an automobile by hand, step-by-step. Instead, the auto moves down an assembly line past a worker who may simply turn a few screws on the chassis. That worker, who spends his day at repetitive, small-motion tasks, is setting himself up for a cumulative trauma disorder like CTS.

Finally, today's doctors have more accurate diagnostic tools at their disposal, so suspected cases of CTS can be more readily identified. The two most common procedures are the nerve conduction study and the electromyogram.

During a nerve conduction study, the doctor electrically stimulates various nerves, including the median nerve, in the hands and arms, and calculates the amount of time it takes for the electrical impulse to travel a given distance. "There are standard values," Dr. Kanner explains. "We know how long it should take a given amount of electricity to travel down a given nerve over a given distance. During a nerve conduction study, we can compare the performance of different parts of the same nerve on the left and right sides, and we can compare different nerves with another and with the standard values."

Electromyography involves the placement of electrodes within the muscles supplied by the nerves in question. That tells a doctor two things: if a muscle has suffered a loss of nerve supply, and if so to what extent -- and it allows him to exclude other possible diagnoses, such as problems arising in the shoulder or neck.

Nerve conduction studies and electromyography are fast and accurate, but they have a major drawback. Both are painful. That's especially true for electromyography, which involves placement of needles containing electrodes into muscles in the upper arm, the palm of the hand and the shoulder and neck.

"I remember it well," says Ginny Schweitzer, a local secretary who has CTS in both hands. "They flipped me over and stuck these needles into the back of my neck, and then they turned on the juice. At that moment, I knew exactly how Ethel Rosenberg must have felt in her last moments."

Treatment for carpal tunnel syndrome generally begins conservatively, with the patient advised to minimize repetitive motion as much as possible, rest the hands as often as possible, and keep the wrist in a "neutral" position, rather than flexed, when working with the hands. Many CTS specialists believe that it's not so much the constant pounding of a keyboard that puts so many typists at risk as it is the tendency of computer operators to keep their wrists cocked up or down while their fingers are working. And most computer keyboards are designed to encourage that posture.

Some patients find relief by wearing a splint at night or at times during the day when they are not using their wrists heavily. Special occupational splints, which keep the wrist in "neutral" while allowing use of the fingers, can also be designed for some patients. Anti-inflammatory drugs, taken orally, help some patients. As a next-to-last resort, some doctors will inject cortisone directly into the carpal tunnel to reduce swelling and pressure. One cortisone injection can bring relief for as long as two or three months, but it does not permanently cure the problem, and doctors are reluctant to keep patients on steroids for any longer than necessary.

Eventually, many patients choose surgery, especially if their hands are painful or weakened. The operation, called a carpal tunnel release, is relatively simple, and patients can choose among several kinds of surgical specialists. Neurosurgeons and orthopedic surgeons frequently perform carpal tunnel release surgery, as do plastic surgeons who specialize in reconstructive surgery on the hands.

According to Dr. Stanley Friedler, an orthopedic surgeon and assistant professor of surgery at the University of Maryland Medical School, it is important that carpal tunnel patients not delay surgery for too long.

"Generally," says Dr. Friedler, "surgery gives terrific results, and the patients are pleased. But if you let the condition go on for ages while you procrastinate about surgery, you can wind up with atrophy of the muscles and scarring of the nerve, and you just won't get the full benefit from surgery that we see in patients who are treated promptly and vigorously. But virtually every patient will improve to some extent. It's just a matter of degree. The sooner you treat it, the less likely you are to sustain permanent damage, and the greater relief you will get from the operation."

Surgery generally takes place on a same-day, outpatient basis under either a local or general anesthetic. It takes about half an hour. The surgeon divides the transverse carpal ligament; room immediately opens up for the nerve, and compression is reduced dramatically. The doctor may also do a neurolysis, during which the individual nerve fibers are separated from one another. Finally, the lining of the canal -- the synovium -- may be partially removed if it has gotten too thick or sticky, as it sometimes does.

For the first few days after surgery, patients wear a compression dressing and a splint. They are encouraged to keep their arm elevated to reduce swelling and to use their fingers as actively as possible. After about 10 days, the stitches or staples are removed, and a smaller dressing is applied.

The total recovery time, during which patients can expect to remain home from work, is roughly two or three weeks, according to Dr. Friedler. "But in the case of a typist or a writer," he says, "someone who is going to be putting more stress on the wrist, it would be better to wait as long as a month before returning to work."

Once the patient recovers fully from surgery, Dr. Friedler says, he or she can do anything. "If they're going back to a cumulatively stressful occupation," he says, "then they might want to wear a special occupational splint, but generally, the surgery affords complete relief and the patient's activity is not restricted."

Other surgeons, however, are less optimistic. Dr. Scott H. Jaeger, executive director of Occupational Preventive Diagnostics Inc., in Cherry Hill, N.J., believes that carpal tunnel patients cannot return to their previous activities after surgery. Addressing the 29th Annual Risk and Management Society Conference in New Orleans last April, Dr. Jaeger remarked, "If we operate on it, we have to put permanent restrictions on their activity. They just can't go back to repetitive activity."

Similarly, an April 1991 article in the Journal of the American Medical Association reported that up to a third of patients who undergo carpal tunnel surgery may develop painful scarring and weakness in their hands.

The study, conducted at the School of Medicine of the State University of New York at Buffalo, found that 57 percent of all patients report the recurrence of some preoperative symptoms, mostly pain and numbness, within two years of surgery, and that 30 percent of all patients rate the results of their surgery as "poor" or "fair" in long-term follow-ups.

At Union Memorial's Hand Center, Dr. McClinton advises caution. "In our classic case of the post-menopausal woman whose symptoms develop gradually, surgery is often extremely effective," he says. "But the 'new' variety of CTS, which affects younger working people, does not always respond that well to surgery."

Dr. McClinton is unsure why that disparity exists in patients' success with CTS surgery. "It's just a guess," he says, "but it may be that when CTS is caused by repetitive motion, more structures than just the median nerve are being damaged. CTS surgery will release the nerve and often end the numbness, but the pain may be unaffected if it arises from trauma to a structure other than the median nerve."

"Please understand that I'm not saying that people with occupational CTS should not have an operation. I'm saying that they need to be counseled about the possibility that they will not have the same recovery time or the same results as their Great-Aunt Sadie had."

Meanwhile, the incidence of CTS continues to mushroom. U.S. Representative Tom Lantos, D-Calif., the chairman of a House subcommittee on employment and housing, held hearings on CTS this past spring for the second time in three years. What the hearings revealed was a potential nightmare for employers and insurers across the country.

The number of repetitive motion disorders reported by American workers increased sevenfold in the last decade, and the U.S. Labor Department's Bureau of Labor Statistics estimates that they now account for 52 percent of all job-related illnesses.

Throughout the private sector, the story has been much the same just since January 1991:

TTC The National Institute for Occupational Safety and Health found symptoms of CTS and related disorders in half the employees of the John Morrell meatpacking plant in Sioux Falls, S.D., and 30 percent of the workers at a Cargill poultry slaughterhouse in Cargill, Ga.

Seventy percent of the grinders at the Electric Boat Shipyard in Groton, Conn., report they are suffering from some form of repetitive stress disorder.

Frank Mirer, health and safety director of the United Auto Workers, estimates that cumulative trauma disorders afflict at least one-tenth of all UAW members.

When the Communications Workers of America surveyed 2,000 of its member operators, 63 percent of them reported suffering from pain or numbness in their hands, and 20 percent had been formally diagnosed with carpal tunnel syndrome.

The Newspaper Guild, based in Silver Spring, Md., found more than 1,500 newsroom employee members with carpal tunnel symptoms.

Seven journalists have filed lawsuits seeking $288 million in damages against Eastman Kodak, the parent corporation of Atex Inc., a leading manufacturer of newsroom computer terminals. The journalists allege that Atex products caused their cumulative trauma disorders. The suit was the second filed against the company for the same reason in the past year.

At Newsday, a Long Island daily paper, a study showed that 40 percent of the company's 800 computer users were showing symptoms of cumulative stress disorders. Four employees filed a $40 million lawsuit against the computer manufacturer.

NIOSH found that 36 percent of the line workers at Perdue Poultry processing plants in North Carolina suffer from carpal tunnel syndrome. NIOSH blamed the disorder on Perdue's failure to obey North Carolina's occupational safety and health laws, and the company was required to pay $40,000 in fines and set up a four-year program to reduce the incidence of repetitive motion injuries among the employees in all of its plants.

In the past year, there have been nearly 73,000 court claims filed in California alone by workers suing their employers and equipment manufacturers for damages from carpal tunnel syndrome.

Although every state, along with the national government, has laws protecting employees from work-site hazards, enforcement has been sporadic in the case of cumulative trauma disorders like carpal tunnel syndrome. And OSHA, the U.S. government's Occupational Safety and Health Administration, was too enfeebled by Reagan-era budget cuts to inspect work sites and punish violators.

But OSHA has begun to step up its enforcement efforts, and employers cannot ignore the rising tide of local legislation and the increased pressure from unions to improve workplace conditions that give rise to disorders like CTS. Both the Ohio and Wisconsin state legislatures are considering laws aimed specifically at protecting computer operators.

San Francisco recently became the first city in the nation to pass a law regulating computer safety in the workplace. The comprehensive legislation deals with danger such as vision damage, muscle and back pain, and radiation dangers as well as with cumulative stress disorders and CTS.

Under the San Francisco law, businesses with 15 or more employees have four years to provide employees who use computers heavily with adjustable chairs and video monitors, detachable keyboards, and 15-minute breaks every two hours. During the first two years of the law's operation, employers must spend up to $250 to retrofit each workstation. At the end of four years, every workstation must be brought up to code, regardless of the cost to the employer.

Increasingly, the San Francisco law is becoming the model for union negotiators and other local jurisdictions around the country. OSHA is also developing a Special Emphasis program to reduce the incidence of carpal tunnel syndrome among workers in the meatpacking industry, and the agency's proposed regulations strongly resemble the San Francisco model.

The magic word is "ergonomics": fitting the workplace to the worker's physical needs. A number of third-party vendors have developed peripheral devices for computers that promise to reduce harmful repetitive stress -- everything from wrist pads to redesigned computer mice and fully adjustable keyboards.

But it will cost employers billions of dollars over the next few years to make even the most basic ergonomic adjustments. The United Auto Workers union, for example, has negotiated contracts with Ford Motor Co., Chrysler and General Motors corporations to establish a program at every work site to identify tasks that can lead to repetitive motion disorders, train workers to reduce harmful repetitive motions, and hire outside consultants to redesign tasks and machinery if the automaker's own efforts fail.

Meanwhile, there is little a vulnerable worker can do to protect him- or herself from carpal tunnel syndrome. Physicians advise people at risk to take frequent breaks and avoid flexing or extending the wrists while performing repetitive tasks like typing and data entry. But that is hard to manage, as any seasoned typist can attest. What's needed -- and what's surely coming in the next few years -- is a comprehensive study and redesign of the way men and women interact with the machines that increasingly define their working lives.

ARLENE EHRLICH is a free-lance writer living in Baltimore.

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