-[IWIF]-

Published in With IWIF-Fall 2002:
Carpal Tunnel Syndrome
Understanding this compensable, costly, and sometimes questionable, occupational disease.

An interview with Dr. James P. Higgins, Hand Surgeon; the Greater Chesapeake Hand Specialists.

Studies have shown that when CTS involves a workers' compensation claimant, recovery time is double that of a non-workers' comp claimant. However, "There is no physiological reason for this," says Dr. Higgins, "because it is the same disease process, the same therapy, and the same surgery."

Repetitive stress injuries-one of which is carpal tunnel syndrome (CTS) -currently account for one-third of the 1.7 million job injuries in the U.S. each year. In Maryland, carpal tunnel syndrome is being reported at alarming rates in all types of workplaces-from the chicken farms of the Eastern Shore to the newspaper pressrooms of Baltimore.

"Carpal tunnel syndrome is now recognized as a compensable claim by the Maryland Workers' Compensation Commission," says Brian Furr, IWIF Attorney. "It is definitely on the rise, and it is costing Maryland employers millions of dollars." IWIF Claims Supervisor Karen Lowrey adds, "CTS does not always require an accident. It is also defined as an 'occupational disease,' which is compensable under Maryland law if it's work-related." Both IWIF professionals estimate it can cost as much as $30,000 per employee-after medical payments, disability income, and permanency awards are made, especially in the case of someone diagnosed with bilateral CTS, or carpal tunnel syndrome in both hands. "And, unfortunately, many carpal tunnel cases involve both hands," says Gale Reikenis, IWIF Nurse Supervisor. "But, it is controllable-and it is preventable."

What is carpal tunnel syndrome?
"The carpal tunnel is a narrow canal at the base of the palm," explains Dr. Jim Higgins, a Hand Surgeon at the regionally renowned Greater Chesapeake Hand Specialists, P.A., in Lutherville. "Carpal tunnel syndrome most commonly occurs when overgrowth and swelling of the tissues create pressure on the median nerve passing through the tight carpal tunnel."

What are the symptoms of carpal tunnel syndrome?
Symptoms include a numbing or tingling sensation, usually associated with the first three digits of the hand as well as the wrist, along with pain and a decrease in strength. Patients may also describe a dull wrist pain and sense of decreased grip strength. They often report that the numbness awakens them from sleep or is exacerbated by strenuous use of their hands.
The symptoms may also be felt with prolonged gripping. For example, gripping a steering wheel, the newspaper, or even a grocery or tote bag may cause pain. Patients may also experience clumsiness when handling objects as a result of their weaker grip.

In advanced cases, the muscle at the base of the thumb may atrophy, leading to loss of strength in the thumb. As the use of the hand and wrist increases with repetitive tasks, the symptoms of carpal tunnel syndrome may worsen, and pain and weakness intensify.
"Treating carpal tunnel syndrome is usually more successful in the early stages of the syndrome," says Dr. Higgins. "Advanced nerve injury, older age, and muscle wasting are factors that make complete recovery more difficult to achieve," he adds. "That's why it's so important to treat the condition as early as possible."

Is CTS a medical condition or work-related injury?
"One common misconception is that carpal tunnel syndrome is always work-related. It is not," asserts Dr. Higgins. "Many factors, including diabetes, arthritis, thyroid disorders, and pregnancy can lead to carpal tunnel syndrome." Other risk factors include gout, renal (kidney) failure, myeloma (bone marrow disease), obesity, bleeding disorders, and infections. Trauma to the hand and injuries to the wrist, such as a wrist fracture or ligament injuries, may also contribute to the condition.

How does one determine whether carpal tunnel syndrome is a medical condition or work-related?
Karen Lowrey, of IWIF, says there's one sure way to tell: "If carpal tunnel syndrome has manifested itself in the first few weeks of employment, we would certainly question the timing. It usually takes months, if not years, to develop." IWIF's Gale Reikenis adds: That's the challenge of the claims adjuster-to determine if this claim is, in fact, work-related or if it is due to other factors."

What causes carpal tunnel syndrome?
Carpal tunnel syndrome often results from repetitive and forceful movements of the wrist during work and leisure activities. Common causes of carpal tunnel syndrome include activities involving highly repetitive wrist motion, holding the wrist in awkward positions for sustained periods of time, and work-task stresses. Another common misconception is that carpal tunnel is limited to people who spend a great deal of time at computers. In reality, it affects anyone who grips something tightly or uses their wrists consistently for a long period of time. Some occupations in which tight gripping or repeated wrist movements are required include cashiers, cyclists, meat cutters, and musicians. Occupations that involve prolonged use of vibrating equipment, such as a jackhammer, are also prone to carpal tunnel syndrome. "Food processors are another category of workers that are prone to getting carpal tunnel syndrome," explains Holly Clark, Senior Loss Control Consultant at IWIF. "The cold environment as with meat packers or butchers can actually aggravate a condition like CTS."

Is carpal tunnel syndrome on the rise?
"Certainly during the past 15 years, there has been a growing awareness of ergonomics in the workplace," agrees Gale Reikenis. "Today, there is a growing awareness of what carpal tunnel syndrome is and how it occurs." One reason for this increase may be that automation and job specialization have fragmented workers' tasks to the point where a given job may involve only a few manipulations performed thousands of times per workday.

Studies have shown that carpal tunnel syndrome is more common in women between the ages of 30 and 60, and that women are three times more likely to have the condition than men.
However, young men and young women who perform highly repetitive tasks in the workplace, such as in the meatpacking industry or on an auto assembly line, are now emerging as a high-risk group. "On an assembly line, you can't adjust the height of the line because it will not be appropriate for the various heights of workers on that line," explains IWIF's Holly Clark. Holly works with manufacturing companies on materials handling and workplace safety issues. "You have to adjust the height of each individual or the angle of the work; otherwise, problems could arise."

How is it treated?
Early treatment is essential for preventing permanent damage to hands and wrists. If left untreated, the crippling pain, nerve damage, and loss of muscle strength associated with carpal tunnel syndrome can result in a permanent disability. Medical treatment options include: (1) splinting of the wrist area; (2) oral anti-inflammatory medications; and (3) cortisone injections. Some health professionals advocate hand and wrist stretching exercises to strengthen the hands. Surgery may be recommended if none of these methods work.

How effective is surgery?
"Improvement after surgery may be dramatic," asserts Dr. Higgins. He cautions, however, that although the surgery is very common, it should only be performed by doctors skilled in peripheral nerve surgery in centers with experience in carpal tunnel surgery. When performed by experienced surgeons, the procedure is low-risk, can be conducted without general anesthesia, and is done on an outpatient basis. The procedure, called "carpal tunnel release," involves cutting the ligament or roof of the carpal tunnel, thereby relieving the pressure on the nerve.
A newer technique, called "endoscopic carpal tunnel release," involves inserting a fiberoptic scope through a small incision to visualize the structures inside of the wrist while incising the carpal ligament. This is the preferred method for Dr. Higgins and his colleagues at Greater Chesapeake. The newer endoscopic surgical methods are preferred because they require smaller incisions and a shorter recovery time, as well as a more rapid return to the workforce. Studies show that more than 80% experience permanent relief of symptoms after undergoing carpal tunnel release surgery.

How soon can patients return to work? Are job changes necessary?
If the individual has had surgery, time off from work may be needed for a few weeks for complete recovery. "Using endoscopic techniques, the patient can expect to return to work in two to three weeks," offers Dr. Higgins. One interesting note of caution: Studies have shown that when CTS involves a workers' compensation claimant, recovery time is double that of a non-workers' comp claimant. However, "There is no physiological reason for this," says Dr. Higgins, "because it is the same disease process, the same therapy, and the same surgery."
When first returning to work, the worker may need to avoid tasks requiring repetitive wrist motion, heavy lifting, and extremes of wrist bending until the condition is resolved. Additionally, protective wrist splints may be used during work and sleep to maintain neutral wrist positions.

Is CTS preventable? If so, how?
By all indications, CTS is not only preventable, it is avoidable. It is extremely helpful for an employer to discover if any factors in the employee's environment, either at work or home, could have contributed to the carpal tunnel syndrome. "If industries and companies address the issue of discomfort first, then they'll avoid the costs of carpal tunnel syndrome," says Wanda Purdy, Senior Loss Control Consultant for IWIF. "My advice to business owners is to work to stop the aches and pains before they get started." She adds: "I'm getting more frequent requests for training on ergonomics and on workplace evaluations. In many cases, employers just need training on how to use the ergonomic equipment they already have."

For more information
For more information on preventing carpal tunnel syndrome and other repetitive motion injuries in your workplace, call IWIF's Loss Control and Prevention Department at (410) 494-2014.

Repetitive Motion Injuries: Not just for office workers
Anyone can get a repetitive motion injury (RMI), the name for the type of injuries caused by regularly repeated movements. Carpal tunnel syndrome, an RMI, affects the hands and wrists, but other parts of the body can also be affected, including the arms, fingers, shoulders, and neck. Occupations to be aware of for potential repetitive motion injuries include:

o Welders
o Auto mechanics
o Painters
o Cashiers
o Glass Cutters
o Phone Operators
o Musicians
o Food Service Workers
o Housekeepers
o Mail Carriers
o Carpenters
o Sewers/Material Cutters
o Meat Packers/Cutters
o Athletes
o Dancers
o Bicycle Messengers
o Assembly Line Workers
o Shipping Employees (who do frequent wrapping or packing)

Greater Chesapeake Hand Specialists, with its main office located in Lutherville, Maryland, is affiliated with the Raymond M. Curtis National Hand Center at Union Memorial Hospital in Baltimore, the regional trauma center for acute hand injuries.

The eight physicians at the Greater Chesapeake Hand Specialists are specially trained in surgery of the hand. They perform most outpatient surgery at the Lutherville "Surgicenter." Care requiring hospital-based services is usually provided at the Curtis National Hand Center in Baltimore. The doctors also maintain privileges at most Baltimore-area hospitals so that their patients may receive care at the hospital of their choice.

Because of its outstanding quality of medical service, primary care physicians and IWIF refer many carpal tunnel claimants to Greater Chesapeake Hand Specialists for diagnosis and treatment.

For more information on the Greater Chesapeake Hand Specialists, call (410) 296-6232 or toll-free 1-800-870-HAND (4263).