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Overuse may cause more pain than carpal tunnel syndrome

By DR O. ALTON BARRON, New York Times

© St. Petersburg Times, published November 22, 1999

NEW YORK -- Almost every day, I see one or two patients with pain in their upper limbs that they attribute to their use of computers at work. These patients are usually young and healthy, but they have a look of apprehension, some fear of the unknown and an overly gentle handshake, as if I might damage them further with a simple greeting. But since they are often on their ever-more-truncated lunch hours, they waste no time beginning their story -- a story I hear with an alarmingly increasing frequency.

They tell me there was a time when they could "pull an all-nighter" typing a 30-page term paper and then work the next day at their part-time computer programming job and never look back. So what gives? They say they have tried rubbing and soaking, herbs and acupuncture, but their forearm, wrist and hand pain persists.

Most of these people thought it could not happen to them, but many can be classified as neo-workaholics bred of the information age. Many have jobs with start-up Internet companies that commandeer their lightning-fast fingers to increase revenues and send their IPO stock prices soaring 800 percent in the first nanosecond.

They are desperate when they come to see me at the C.V. Starr Hand Surgery Center in New York. Their hands, the foundation of their livelihoods and well-being, are in pain, and they feel vulnerable and frightened. They have heard horror stories about others who have lost the use of a hand after the onset of mild symptoms similar to what they are experiencing. I ask questions, and they tell me their story.

"How long have you had the pain in your forearms?"

"About two months."

"Have you ever felt anything like this before?"

"Maybe once or twice in college, around finals, but it just went away in a day or two."

"Have you had any specific injuries?"

"No. Do I have carpal tunnel syndrome?"

"It doesn't seem likely based on your symptoms. Are you otherwise healthy?"

"I guess so, but I'm beginning to wonder. Am I just starting to fall apart now that I'm over 30? Is it downhill from here?" (I reassure them that this is by no means the case.)

"Has there been any significant change in your work habits?"

"Well, I changed jobs three or four months ago. I mostly just type at a computer, probably six to eight hours a day, unless a deadline is near, then it's more like 10 or 12. At my old job, it was more like three or four hours a day."

"Do you exercise regularly?"

"With this new job? There's no time."

"Do you feel any numbness, tingling or pins and needles in your hands?"

"Not really, just some strange sensations that move around, run up my arm. Are you sure I don't have carpal tunnel syndrome?"

Their physical examinations usually are remarkable for the absence of findings that point to common upper limb problems. There may be tenderness in the forearm muscles, mild stiffness when bending the wrist in each direction and some pain with forceful grip. The most notable finding is a weakness of grip and a weakened ability to pinch.

The diagnosis is overuse strain, and it can threaten one's psychological, physical and financial health. It is not carpal tunnel syndrome or whatever the latest Internet chat room or late-night TV commercial may be claiming to have discovered the cure for. Patients have been assaulted with so much information invoking such disquieting terms -- such as RSI (repetitive stress injury) and OSHA and CTS (carpal tunnel syndrome) and CMV (cytomegalovirus, of chronic fatigue fame) -- that they imagine the worst. A simple, readily explicable and treatable problem becomes distorted, and the patient suffers.

Overuse strain appears in all facets of life. When a formerly serious runner decides to return to running after a year's layoff, he is at great risk. This gung-ho Type A in new Nikes runs 19 days straight, and then shin splints, Achilles tendonitis and knee strain, topped off with a dollop of sciatica, set in, bringing the runner painfully back to Earth. It is clear that the would-be athlete went too far too fast. What happens when people do the spring cleaning after a long, cold winter? They ache all over and start popping ibuprofen and begging for massages.

In the workplace, overuse strain has the same origin, as people alter their use patterns enough to take their limbs beyond a previously adequate level of conditioning. That often seems due to the patients' own dedication to their work and their employer as well as external pressures to maintain high productivity and meet deadlines.

I find the phrase "repetitive stress injury" problematic. Professional violinists, percussionists and other musicians can play several hours a day for decades without sustaining such "injuries" -- if they avoid abruptly pushing beyond their level of conditioning. The large typing pools of decades past seem to have been largely free of endemic typewriter-induced RSI. That is logical because these typists did the same work all day, every day, leaving them well conditioned and at less risk for overuse strain.

In contrast, our society's excessive work ethic and unrealistic deadlines leave many people much more susceptible to injury. By implicating the computer mouse or keyboard, per se, we miss the point. Ergonomic office evaluations are certainly valuable, but they should not supersede efforts to educate employers and employees about the causes of overuse strain and to encourage work habits that minimize the risks for such a problem.

What to do? Naturally, people in pain should see doctors and not try to diagnose their own problems. And they should do it quickly. As with many medical conditions, early detection means an earlier cure. Usually, a problem only gets worse with time.

To avoid ending up in pain, one of the most important things to do is avoid large fluctuations in hours spent each day or week at the computer. And be aware that job stress, and the resulting changes in posture and muscle tension, can have an effect on your body. Many patients have told me that the force with which they grip their mouse is directly proportional to their stress level.

Through experience, we come to expect that our shoulders and arms will be sore after painting the ceiling of the family room or moving furniture on a weekend. Through education, not sensationalism, in the workplace, on the streets and in the media, we can begin to recognize when we are putting ourselves at risk for overuse strain and take actions to prevent that.

-- O. Alton Barron, M.D., is a physician at the C.V. Starr Hand Surgery Center at Roosevelt Hospital in New York.

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