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Hands-on approach to avoiding Carpal Tunnel Syndrome.

Hands-on Approach To Avoiding Carpal Tunnel Syndrome

Corporations have spent millions of dollars on the fallout effects of Carpal Tunnel Syndrome (CTS). Some of the many costs of the syndrome involve replacing workers and providing them with hospitalization, physical therapies and workers' compensation. Lost productivity and extended sick time are other major expenses, which will be incurred until the condition is finally treated. There is also the human cost of a worker having to leave the dignity and stability of a job, either temporarily or permanently.

Between 25 and 35 percent of all productivity workers, between ages 30 and 35, will show evidence of Carpal Tunnel Syndrome at one time or another. CTS, however, only affects 1 percent of the general population. Since it represents a significant potential liability to corporations, risk managers would do well to become experts on its prevention, warning signs and various courses of treatment, from non-invasive to operative care.

What is CTS?

Carpal Tunnel Syndrome begins with an injury caused by repetitive wrist movement, such as cutting meat, working on an assembly line, typing or operating a computer. The injury produces a scar which presses on the median nerve located in the wrist's carpal tunnel. Pressure causes nerve damage which, in turn, creates numbness, tingling, burning sensations and, eventually, loss of muscle strength in the wrist and first three fingers. As a result, it can become almost impossible to open a jar or button a shirt, or, for that matter, to do one's job with competence and efficiency.

In its most advanced state, CTS is completely irreversible, but if detected early enough, a variety of therapeutic measures can alleviate some of its worst symptoms. If these ultimately prove insufficient to allow a complete return to work, there is a relatively new--but relatively uncommon--outpatient operation that can provide a complete cure for the condition, and not plague the employee, employer or risk manager ever again.

Prevention is Key

Prevention, obviously, is the first and best step for risk managers to take in handling this problem. Creating a work environment that will deflect stress on the wrist as much as possible will in the long run save treatment costs and keep productivity at optimal levels. It will also prevent the general disruption caused by worker absences and complaints.

Preventive measures might include such simple things as resharpening the knives that are used hundreds and hundreds of times a day by meat cutters. Another example would be to change the angle or height of a chair to limit the amount of hyperflexion and hyperextension of the hand that occurs during the course of a typical workday. This will keep the hand in a more neutral position, in which it will be less stressed more of the time.

Another strategy is to rotate the types of jobs workers perform, so no one worker does the same task for more than a few hours at a time. For example, one study concluded that CTS was more likely to be the result of overtime, even when a worker was performing at an average level, as opposed to a fast worker, working a regular, eight-hour shift. Simple changes can make a big and lasting difference to a company's potential liability picture, and safeguard workers who represent a valuable resource and company investment.

Diagnosis is First

After prevention comes diagnosis. CTS is often misdiagnosed as a variety of other ailments, such as a pinched nerve in the neck, arthritis of the wrist or poor circulation in the hands. With older people, CTS is typically related to arthritis since the inflammation and swelling of arthritis will squeeze the nerve. In fairly young people, CTS can be a secondary result of tendonitis which also produces swelling and tends to compress the nerve in the carpal tunnel. People with diabetes or thyroid trouble are prone to CTS because their nerves are already, in most cases, weakened by illness.

The first step in correctly diagnosing CTS is to obtain symptomatic histories: when, how long and to what degree are symptoms, the numbness, burning and tingling sensations, occurring? Is the patient woken in the middle of the night by hand numbness? Does pain radiate up the arms? Does the patient experience a loss of grip or a loss of sensation in the hand? Is the muscle atrophied upon examination by the physician?

When the symptoms appear to be present, the next step is a diagnostic test known as an electromyogram. This test measures the electrical conduction of the nerve across the wrist. An electrode delivers an electrical impulse to the nerve, and another electrode carries the impulse out to measure the speed by which it travels. Delayed conduction indicates nerve damage. However, in some cases where pain and discomfort are severe, actual nerve damage may be minimal. In those cases, the electromyogram would not prove "abnormal" and treatment might, at this point, succeed with noninvasive strategies. The electromyogram helps physicians rule out other possible causes for CTS symptoms.

Therapy Follows Suit

After diagnosis comes therapeutic treatment to alleviate the syndrome's symptoms. These nonoperative medical techniques can include a special wrist splint worn at night to keep the hand and wrist in a neutral, nonstressed position. A splint can even be worn on the job, though this tends to inhibit movement, becoming more of a hindrance than a help. At times, a single injection of steroids into the wrist ligament will ease some of the pain. Rest itself can reduce symptoms, and the longer the rest, the better. Noninflammatory agents, such as Motrin or Advil, can often help, at least, for the short-term.

When the damage is too severe or has gone untreated for too long, the only remaining option is surgery, though even this can prove futile. There are currently two forms of surgery available for CTS: the older, more traditional procedure, requiring general anesthesia and many weeks to heal, and the newer, outpatient procedure, requiring only local anesthesia and just a few weeks to heal. The latter is known as the carpal tunnel release operation.

The open procedure involves opening the entire hand and wrist, doing a great deal of damage and potentially causing permanent injury if everything does not go exactly right. The open procedure can require a total of six months to operate, wait, operate again and wait again before a return to work will be possible. Because recovery is so slow, use of the hand and wrist is restricted for a long time following the surgery. It is quite painful and takes a worker out of the job situation for up to three months.

By contrast, it is no more effective than the closed release procedure, which is far less damaging, involves only a brief outpatient operation and requires just three stitches. Further, both wrists can be operated on at the same time, and the patient can begin, and is encouraged to use the wrists right after surgery to strengthen and rebuild the atrophied muscles. Sensation returns immediately to the fingertips with release surgery, allowing the patient to perform such important tasks of daily living as buttoning shirts and opening jars.

With the carpal tunnel release operation, the bulky dressing placed on the wrist right after surgery will be removed in 24 hours and replaced by a simple bandage. In a day or two, those who are self-employed can return to their jobs, limited only by the degree to which they feel a kind of pulling due to the healing or even brief sharp pains. These symptoms disappear within a week or two. After the usual two-week recovery period, however, and depending on the severity of the nerve damage prior to surgery, the patient will be able to return to work with full use of the hand or hands. Carpal Tunnel Syndrome should not return, and the operation should result in a complete cure.

The release operation typically costs between $800 and $1,000 with no hospital stay, no recovery room stay, no general anesthesia and no physical therapy. It is strictly an outpatient procedure, with one additional office visit to remove the stitches a week after surgery. The only physical therapy involved is a ball of hand putty usually given to patients to squeeze and knead to help increase muscle strength.

By contrast, the older, more extensive operation is generally more expensive. The expense of the open technique is reflected in more loss of work and lost productivity in addition to anesthesia, therapy and follow-up visits.

Because of the costs and magnitude of the problem, risk managers must take primary responsibility for heading off Carpal Tunnel Syndrome by stimulating greater awareness of CTS and its potential for occupational disaster. Educational efforts should be a major part of any preventive program, and judicious alterations in the workload and work environment should support those initial campaigns.

David M. Pagnanelli, M.D. is chief of neurosurgery at Abington Hospital in Abington, PA.
COPYRIGHT 1989 Risk Management Society Publishing, Inc.
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1989 Gale, Cengage Learning. All rights reserved.

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Author:Pagnanelli, David M.
Publication:Risk Management
Date:May 1, 1989
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