Monday, 29 September 2008

Work Related Upper Limb Disorder, WRULD, Repetitive Strain Injury, Carpal Tunnel Syndrome

Work Related Upper Limb Disorder

Carpal Tunnel syndrome is often just another form of Repetitive Strain Injury (RSI). Other names include De Quervains synovitis when it is so bad the tendon "crackles", golfer's elbow, tennis elbow, sometimes frozen shoulder, dystonia (Awkward movements), writers' cramp, and good old myalgia (Pain in the muscles). In truth all these conditions have the same underlying cause. The results are stiff, painful, swollen and tender muscles in the hands, arms, shoulders and neck. The swollen muscles put pressure on the nerves. The Carpal Tunnel is literally a tunnel at the wrist, through which the nerves and tendons to go through on their way to the hand. As this is a narrow point, it is not surprising it becomes painful.
Upper Limb Disorder (WRULD) .
The pain from WRULD can be horrific, it can keep a person up at night, it can prevent them doing everything and anything physical. However the good news is that, with the right treatment, it gets better.
Similar problems can happen in the lower limbs, - runners used to call it "Shin Splints".
Work Related Upper Limb Disorder can cause pain at any point - from the wrists, to the elbows, shoulders and neck. However although the pain may be intense at one point in the Upper Limb "girdle", it is always possible to find evidence of this condition elsewhere in the shoulders, neck and arms.
How can you tell if someone has WRULD?
Diagnosis - depends on finding a characteristic pattern of pain and physical changes. (Medical term - "signs and symptoms")
The problem (Medical term - Presenting complaint) is pain and discomfort in the wrists, arms, shoulders and or neck.
The pain of WRULD gets worse with work or the activity and better when a person rests
WRULD is often set off by a relatively minor injury that does not get better. The body naturally heals, almost regardless of what we do to it. If pain or a minor injury is not healing, something else is happening, and one reason may be that the person has underlying Work Related Upper Limb Disorder.
WRULD leaves clues. Before WRULD was recognised and understood, employees complaining of pain while they worked were seen as "sciving". In truth, people with WRULD are not scivers, these are the hard working employees. The subtle changes that indicate (Medical term - sign) are readily seen, once you know what to look for.
The Symptoms:
Pain - the pain may be any where in the mechanism, just as a bridge will tend to crack at its weakest point, so the pain will tend to be felt at the "weakest" point, perhaps where there has been an injury. Nonetheless, the whole bridge is under pressure, and it has cracked at its weakest point. In order to repair the bridge, it is necessary not just to work on the crack but also to look at what it putting the bridge under pressure.
The cause:
Repetitive limited movement under pressure. Most often this is work related, typically typing although I have seen WRULD associated with many different occupations, from driving and train driving to ticket sales - especially the turntables beloved of railway ticket offices, packing, counting and any kind of keyboard work.
Anyone who is not a traditional shape or size is at particular risk - for example, if someone is more than 5' 9" or less than 5' 4"
Over the last ten years, employers, Human Resources and employees generally have become more aware of the problem. Work station assessments, which make sure people are in the correct ergonomic position and as a result WRULD is less common than it was perhaps five years ago. Nonetheless, this also means that those people who do have WRULD can be more difficult to diagnose than in the past.
Work Related Upper Limb Disorder is the result of overusing one set of muscles whilst working under pressure.
Signs of WRULD
Tender muscles:
Firmly touching the muscles of arms, especially around the elbows, even the biceps, especially around the shoulders and neck, causes if not pain, definite discomfort. Muscles should not be tender!!! they should be soft, pliable and flexible. If muscles are stiff and painful, something is not right! - they have been overused or abused in some way. Typing, driving, playing tennis, sitting in an office are not natural activities and they have a cost, even though they may be fun and even good for you when done properly!
Stiff muscles:
Almost everyone can pinch their shoulder blades together at the back. However if someone has WRULD, their muscles are stiff and they find it difficult to "roll" their shoulders and cannot pinch their shoulder blades together. When I test for this, I put my finger on the person's spine and ask that person to squeeze my finger. This sign is always present - almost to the point that if a person has sufficient flexibilty to squeeze my finger they cannot have WRULD and if they are too stiff, then they are at risk of WRULD.
Squeezing your shoulder blades together at the back could be useful part of every work station assessment!

This is the One Minute Doctors's approach to RSI

1) RSI is caused by repeating one action or activity or a limited range of activities. Any activity done often enough, can cause RSI. From counting tickets, running on running machines (yes any limb, any activity - it used to be called "shin splints"), writing, data entry, to good old typing.

2) Hard working types get RSI. People going for the Word Speed Record, or Ticket Counting Tally. It is not a condition for idlers or the faintheartedly. Their enthusiasm means they ignore the first warning signs of pain and stiffness and wait until it becomes seriously painful.

3) RSI causes pain and stiffness in all of the muscles of the arms, shoulders and neck. The person is usually tense and rigid, and highly focused on work, and they do not notice the pain that this causes. This may be the only exercise they get. Wrists, hands and shoulders are stiff, often on both side and he or she can never pinch their shoulder blades together at the back.

Shoulder stiffness might almost be seen as diagnostic, and where you find shoulder stiffness you will also find neck stiffness as well as arm stiffness.
Treatment is three fold

1) Stop it - whatever it is that is causing the problem, whether typing, driving or an obscure hobby
Stop or reduce the activity - that is complete rest until pain goes and then start from scratch gradually increasing the activity with frequent breaks. This may be every ten minutes to at the beginning

a) Voice recognition software, but it can be difficlt to train a computer and you have to speak to it slowly
b) Dictate the reports and get them back from India four hours later, ready for editing - for example,

2) Do the it differently -

a) work station assessments to make sure the person's posture is correct,
b) wrist rests and other aids, to make sure the person keeps their joints in a neutral position. For example, Track Balls instead of mice, big pens that are easier to grip and so on.
c) change your typing position - most of learn to type in a hit or miss sort of a way. A proper old fashioned typing coure can help someone unlearn bad habits and learn to type better and more effectively

The neutral position is the most efficient way to work a muscle and joint. Extending or stretchig to work at a distance from the body means that the muscles do not work efficiently. This causes pain quicker than if the joint or limb is held in a comfortable neutral position.

3) Loosen up !

a) Physiotherapists are best at managing RSI. They intuitively understand that all parts, wrists, arms, shoulders and neck need treating. Physio is essential if you want to solve the problem and prevent it coming back
b) learn to fidget rather than sit still - stretch and shake yourself out every few minutes, change positions, shrug your shoulders, keep moving!
c) do different physical activities - like dance, yoga, pilates, Alexander technique, different sports, gardening and other outdoor pursuits, rather than just the gym. Do a different type of exercise every day.
d) learn to relax and enjoy the day, rather than keep trying to chase your tail faster and faster - the harder you chase your tail, the faster it moves. Do things differently!
e) Quick exercise = Roll your shoulders forwards, Roll your shoulder backwards and shake your arms out! 10 of each every twenty minutes as required.
What not to do!!
1) Take painkillers in order to continue working without sorting out the problem
2) Have an operation
Surgeons are tempted to relieve the pain by operating on the Carpal Tunnel.
a) no one knows what happens in the long term when a youngster has this surgery. It reminds me of the enthusiasm with which cartilages were removed from knees in the 1970s an 1980s and the knee pain and osteoarthritis which inevitably followed in the 1990s and 2000s .
b) It does not treat the cause, just one symptom.
Patients should always be wary of having surgery, especially on "soft tissues", that is muscles, ligaments and tendons. Operating on something that has taken millions of years to evolve and was fine until the turn of the century is rash. Especially as the cause relates to our unnatural lifestyles, poor typing posture, intensive work and too few breaks. At best surgery relieves the symptom, at worst it is storing up problems for the future.

I wrote this post because this morning, I saw a young girl heading for surgery for her "Carpal Tunnel Syndrome". I was left wondering why after millions of years of evolution, and some of the finest biological design work imagineable, does a person suddenly need their wrists cut open in order to lead a normal life?

Copyright (c) Dr. Liz Miller

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