Getting a Grip on Hand Problems
by Cheryl Platzman Weinstock

     A trip to the supermarket or signing a paycheck didn't
used to rank high on the list of 31-year-old Wanda Wood's
concerns. But now, everyday chores like pumping gas and
carrying groceries to the car are ordeals for her.
     Wood can't hold a pen long enough to finish signing
her check. She has trouble grasping a nozzle to fill her
gasoline tank. And she can't grip her groceries to keep them
from falling out of her hands.
     "It's when a jar of tomato sauce cracks all over the
pavement that I get real embarrassed," said Wood, a
Richmond, Va., former postal worker. "It's pretty tough to
handle when you're standing in a parking lot covered with
red goo."
     Like Wood, an increasing number of American
workers are experiencing the sudden onset of one of several
cumulative trauma disorders affecting the hands, according to
James McGlothlin, Ph.D., a research hygienist at the National
Institute for Occupational Safety and Health in Cincinnati.
Doctors often call them repetitive strain injuries (RSIs).
     RSI is a catch-all term used to refer to many painful
conditions, such as trigger finger, nerve spasms, and carpal
tunnel syndrome. They can cause stiffness, swelling, tingling,
weakness, numbness, and, in some cases, irreversible nerve
damage.
     Carpal tunnel syndrome is the most frequently
reported RSI, with 192 cases per 100,000 workers in 1989,
according to the U.S. Public Health Service. It occurs when
tissues on the palm side of the hand swell, compressing or
entrapping the important median nerve, which runs through
this area. Numbness and tingling usually start in the wrist,
and can radiate down to the thumb and fingers, or up to the
elbow. Many patients feel pins and needles when their wrist
is tapped. Weakness occurs on effort. For example, patients
may suddenly drop objects they are holding. A nerve
conduction test, a recording of the electrical activity of the
hand and arm muscles, is helpful in diagnosing this disorder.
     Other RSIs include nerve spasm and "trigger finger."
When nerve entrapment and the pressure caused by it occurs
over a long period, the nerve can become irritated and go
into spasms, stimulating muscle activity that eventually causes
pain similar to severe muscle cramps.
     When finger tendons, fibrous bands of tissue that
connect muscle to bone, get irritated, they can grow nodules,
which, at the points of attachment, get caught in the
lubricating sheath that surrounds them. When this happens,
the finger can become stuck; this condition is called trigger
finger.
     RSIs are self-limiting conditions that result from
excessive use of the muscles and tendons of the hands, wrists
and forearms. Meat cutters, auto workers, cashiers,
journalists, keyboard operators, and others who spend long
hours at repetitive chores are particularly vulnerable.
     Wood used to spend long shifts operating a letter
sorter, typing hours at a time at a computer keyboard to
route the mail to its destination.
     "My pain eventually became so severe that it worked
its way from my fingers to my wrist to my elbow until it felt
like a constant crook in my neck," she said.

Hopes for Help
     Because the consequences of these disorders are so
high, the goal of safety and health professionals across the
country is to collect information on which to base decisions
about the best ways to prevent and treat these illnesses.
     But this is not an easy task. For example, some
proposed treatments have not been substantiated by
controlled clinical trials.
     According to John Vanderveen, Ph.D., director of the
Food and Drug Administration's division of nutrition, "We
have from time to time dealt with claims for the use of
nutrients to prevent or treat carpal tunnel syndrome, but
could only find anecdotal reports."
     He said, "It's difficult to do such studies because
animal models are more tenuous to tease out pain and
performance data from than humans. So right now we don't
know if basic clinical research is likely to support such
claims."
     In addition to RSIs, various forms of arthritis can
cause hand problems. Rheumatoid arthritis, for example, is a
chronic, autoimmune disease affecting the entire
musculoskeletal system. Osteoarthritis, a degenerative, "wear
and tear" condition can also affect the hands. (See "Arthritis:
Modern Treatment for that Old Pain in the Joints" in the
July-August 1991 FDA Consumer.)
     Vanderveen said researchers are investigating the
innovative use of omega-3 fatty acids, found in fish oils, to
help suppress the disease by curtailing production of
prostaglandins, a series of hormone-like substances associated
with inflammation that occurs in arthritis. Vanderveen
cautions that it's still premature at this time to think that
these fatty acids will be therapeutic for many arthritis
patients.
     Today the best bet for RSI patients is to cope with the
condition in ways similar to patients with arthritis. Such
coping skills include protecting and caring for their joints and
using OTC drugs such as aspirin or ibuprofen (Advil, Nuprin,
Motrin IB) for mild to moderate symptoms or prescription
NSAIDs (nonsteroidal anti-inflammatory drugs) for stronger
anti-inflammatory relief.
     A general practitioner can treat these disorders, in
most patients, with either exercise, rest, aspirin, or NSAIDs,
such as Motrin or Naprosyn. But if relief does not occur
within a few weeks, the physician may refer the patient to a
specialist.
     Occupational therapists can also help patients with
these disorders to practice "joint protection," according to Jan
Chmela, director of Sheltering Arms Day Rehabilitation
Program in Richmond, Va.
     Chmela, herself an occupational therapist, said that
patients can learn to use their hands in "non-deforming
positions." For example, instead of grabbing a key with a 
thumb and twisting, patients can learn to turn a key with
adaptive equipment. They can learn to use their largest joints
for a job, rather than their smaller, more vulnerable ones, for
opening a jar, for example. She advocates teaching patients to
use their hands closest to their anatomical position,
outstretched as much as possible instead of twisting and
turning them, because bending the hands stresses the joints.
     As with most other disorders, however, prevention,
where possible, is the best cure.
     The National Institute for Occupational Safety and
Health is focusing research on ways to redesign the
workplace to make RSIs less likely.
     The agency's McGlothlin said, "We don't want to try
and fit the worker to the job, but the job to the worker, and
that can best be done through engineering controls so that
both the worker and the company benefit."
     For instance, he suggests adjustable-height tables to
accommodate workers of different heights and builds.
McGlothlin also stressed that employers must be sensitive to
the extreme demands on many of their workers and allow for
recovery time.
     "There are more and more demands on people these
days. Many work two jobs or through the night. Women in
the workplace may also be raising families. Employees need
time off to rest. In order for ideas that we've developed to
succeed, there has to be a partnership between workers and
their companies to make it a more productive and helpful
workplace," he said.
     Employers can also cut down on RSIs by providing
their workers with chairs that give them better postural
support and adjustable work stations that allow them to
adjust their screen, keyboard and wrists.

Diagnosis Important
     Forty-three-year-old Barbara McGhee, a public affairs
specialist at a Virginia Department of Health and Human
Services Social Security Administration office, was diagnosed
with rheumatoid arthritis at age 19.
     Over the years, her hand joints have become rigid and
misshapen by chronic inflammation. Her hand dexterity is
poor--just shuffling through the pages of a book is difficult.
     When McGhee first heard the diagnosis, she said she
refused to despair. "I went to the library and learned all I
could about it." Because unrealistic expectations only make it
that much harder on patients, McGhee said she "needed
information so I could make some important decisions. I
needed to learn what I would and would not be able to do."
     "I realized my attribute was my high energy level and
if I cultivated it, I could put it to good use." Twenty-four
years later, she is unable to waterski or horseback ride or
participate in other sports she used to adore, but she has
nevertheless found her niche. McGhee not only holds down a
full-time job, but also volunteers for her local chapter of  the
Arthritis Foundation and the Richmond Mayor's Commission
for Disabilities.
     McGhee said she only wishes that she hadn't waited
five years from the onset of her problems to seek the help of
a physician. She said she wonders if she had paid attention to
her condition earlier whether she could have avoided having
one wrist and one ankle replaced, and the other ankle fused.
     Because aches and pains are commonplace, people
with early morning stiffness, difficulty in movement, or
tenderness in one or more joints sometimes do not realize
that they may need to see a doctor.
     But it's important that people whose symptoms last
longer than several weeks see their physician immediately.
For example, in some cases of moderate to severe carpal
tunnel syndrome, early treatment can prevent significant
permanent damage to nerves.
     Hayes Willis, assistant professor of medicine, division
of rheumatology, allergy and immunology at the Medical
College of Virginia, explained that, "damaged nerves just
don't heal well."
     He added that for both arthritis and RSIs, the earlier
a diagnosis is made, the greater the likelihood of minimizing
disability. n

Cheryl Platzman Weinstock is a writer in Long Island,
N.Y.,who specializes in health and science issues.
For More Information
     For further information about repetitive strain injuries,
call the National Institute for Occupational Safety and Health
at (800) 356-4674.
     For information and referral 24 hours a day about
arthritis, call the Arthritis Foundation's National Hotline at
(800) 283-7800. The hot line can provide local chapter
numbers and brochures that address many of the physical,
emotional and coping problems that arthritis patients can
face. The impact of arthritis on the family, pain management,
proper exercise, and up-to-date medication information is
available. 
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