Carpal Tunnel Controversy
Back belts. Wrist braces. Wrist pads and splints. Swedish chairs. Trackballs, instead of computer mice. All devices that were supposed to make life easier for people afflicted with repetitive stress injuries on the job. And all of them, Steve Moss contends, have either been proven useless or remain controversial. Some of them even make things worse.That Steve Moss would take this view is unsurprising. An economist hired by a business coalition to fight California's pending ergonomic standard -- the first of its kind in the nation -- Moss has determined that the requirement could force business to spend at least $9.7 billion over the next ten years, much of it from within the vast desk-and-terminal landscape of Silicon Valley. The effort would involve evaluating worksites, replacing desks, modifying keyboards, and investing in an array of unproven gadgetry that more closely resembles a set from Star Trek, The Next Generation than a Herman-Miller office. He and associate Peter Berck, a UC-Berkeley professor, also estimate that the Golden State could lose as many as 12,000 jobs as some businesses decide it would be cheaper to automate or flee the state for less ergonomic pastures.While Moss' view is predictable considering the clients he represents, other viewpoints emerging around the debate have been surprising. In fact, Moss' contentions about so-called "ergonomics" echo what physicians have been saying quietly for years -- that despite the increasing frequency of classifications such as carpal tunnel syndrome and repetitive stress as on-the-job injuries, the science of preventing this collection of diseases is almost nonexistent. And furthermore, the condition reported in hundreds of thousands of disability cases a year may not have roots in the workplace at all.Last week, the state Senate Industrial Relations Committee heard testimony on a bill which attempts to scuttle the state's controversial ergonomic standards in their tracks. Labor representatives pushing for workplace safety testified against the bill, and business organizations who would pay the price lobbied in favor. California's standards would apply to every business or government agency reporting more than one employee with a case of a so-called repetitive strain injury like tendinitis or carpal tunnel syndrome. If a physician believes that those cases are related to work, the employer would have to buy equipment, train workers or change work patterns to alleviate the problem.According to a committee staffer present at the hearings, every physician who testified spoke against the ergonomic standards. In fact, both the California Orthopaedic Association and the California Medical Association have gone on record backing the bill to eliminate the ergonomic regulation. "Currently the scientific literature cannot explain why one employee working next to another and performing the same activities may suffer discomfort or pain while the other does not," explains Ramon Jimenez, a San Jose California orthopedist and president of the orthopedic association. "We don't know yet whether changing the ergonomics -- chair, type of computer, wrist pads -- can help. It may help some people, but not all. If we try to modify what they're doing, the effort to stop one inflammation can sometimes even cause another."The fight over the standards reveals a deep fissure in the medical community, as physicians argue over how often repetitive strain injuries are work-related and whether the term "repetitive strain injury" is even a valid one. Even the different disciplines in medicine are divided on this issue, with hand surgeons frequently skeptical about the injuries, occupational medicine specialists putting more faith in ergonomics, and orthopedists somewhere in the middle. The medical debate may have helped sink a drive for ergonomic regulations at the federal level last year. Now, as California debates whether to become the first state in the nation with such standards, legislators who listen to science may decide against ergonomics.Doctors do not deny that the numbness, aching and pains that their patients feel are real, or that they are often suffering from physical diseases. They hear about it all too often, to the tune of more than 300,000 cases in the country annually, and most commonly prescribe anti-inflammatory medication.For some doctors the problem starts with "cumulative trauma disorder" and "repetitive strain injury," which are umbrella terms encompassing injuries such as carpal tunnel syndrome (which tends to affect typists), thoracic outlet syndrome (known to affect pianists) and tendinitis. The terms imply that these injuries are caused by repetitive motions, which also implies that the obvious cure is to stop those motions. In fact, many doctors say that sometimes the motion only exacerbates or brings out a problem that may have other causes.Carpal tunnel syndrome is one of the most well-known forms of repetitive strain injury, or RSI. Some media reports give the impression that it is an almost inevitable result of working at a computer terminal all day. But "there's not a shred of evidence that [carpal tunnel syndrome] is caused by using a computer," says Morton Kasdan, an editor of the Journal of Hand Surgery and former president of the American Society for Surgery of the Hand. "There's not a single prospective, controlled study in the literature which shows that it does anything."Kasdan blames workers' compensation and hysterical media reports for the rise in complaints of carpal tunnel and other RSI diseases. "If you look at the rise in insurance claims for this stuff, you'll see it's directly related to insurance reimbursement." He claims that incidences of such diseases dropped dramatically in Australia after courts ruled that they wouldn't be covered by workers' comp without objective testing.In the past decade, reports of repetitive strain injuries have increased nearly thirteenfold to a total of more than 302,000 in 1993, according to a recent report by the Bureau of Labor Statistics.Kasdan and his fellows in the scientific orthodoxy believe that only certain extremely forceful work activities can lead directly to carpal tunnel syndrome, like jackhammering and weightlifting. Kasdan believes that most other cases of carpal tunnel stem from other problems: obesity, diabetes, smoking, poor physical conditioning. To treat carpal tunnel, Kasdan typically prescribes not wrist braces but exercise or weight loss.Kasdan is generally reluctant to provide his patients with time off work. He's afraid that it will cause patients to label themselves as disabled. To patients who feel pain every time they type on a keyboard, the prescription is sometimes hard to swallow. "If you tell them it's not created by work, [some patients] start hollering in the waiting room. But I've never had the insurance people do that. Enough physicians have been burned that they learn it's much easier to say the problem is work-related. They keep their patient and get more money."Another problem faced by doctors handling repetitive motion injuries is that sometimes there is no verifiable injury accompanying the symptoms. Carpal tunnel syndrome is frequently defined as a painful entrapment of a nerve in the carpal tunnel, a small opening between bones in the wrist that is crowded with blood vessels and tendons. Peter Nathan, a hand surgeon in Portland, has done several studies in which he measured whether the median nerve was conducting smoothly through the carpal tunnel. Nathan found that some who reported carpal tunnel symptoms like numbness and tingling still had good nerve conduction. Instead, he found that true carpal tunnel injury had little to do with the type of job or length of employment a patient had. Instead, it was more likely to be found among women, the elderly, the unfit and those with small wrists.Some studies have even shown that repetitive motion injuries are more likely to affect people who are unhappy with their jobs. The findings imply that employers and workers should concentrate less on painful symptoms and more on making jobs satisfying.Still, these studies don't jibe too well with the RSI support group that meets at a physical therapy clinic in Palo Alto, California. At a gathering last month, a collection of folks who looked mostly fit, mostly young and about half male went through a series of relaxation exercises with a master of tai chi, the meditative martial art.Silicon Valley workers may recognize cases like that of Duggan Dieterly, one of the most productive programmers in his unit at Hewlett-Packard before he developed soreness and stiffness in his wrist and elbow. Clean-cut and articulate, Dieterly says that at first he ignored the pain. By the time he went to a nurse, he had already gone, in his words, "down in flames." He couldn't use a cash machine or a phone. His wife had to feed him. A couple months off work made little difference. Diagnosed with tendinitis and fascitis, Dieterly has run through a series of doctors and physical therapists. Only herbal medications seem to have any effect. Dieterly is a victim of what is known as "chronic pain," one of the thorniest problems in modern medicine.Cathleen Smith strolls through ErgoCon, the ergonomics convention held in Palo Alto last month, until she reaches the booth with the vibrating floor mat. She scrunches up her features, obviously skeptical. "Has there been any research on this?" she asks the salesman at the booth.Smith is the ergonomic program manager at Silicon Graphics Inc. in Mountain View. The computer manufacturer is one of a number of Silicon Valley companies where escalating workers' compensation costs and pending ergonomic standards spurred an ergonomic program. At Silicon Graphics, the program includes ergonomic training classes, individual workplace evaluations, and an "ergonomic center" where employees can try out different kinds of office accessories for comfort.Smith says her program has been a big success at Silicon Graphics. Within four years, repetitive motion injuries dropped from more than 40 percent of workers' compensation costs to just 15 percent. Back injures on the manufacturing floor were cut nearly in half after only two years of back lift safety training. But Smith acknowledges that the fledgling ergonomic market is a minefield. "You can't just seize on any new gimmick on the market. For example, there are a dozen alternative keyboards out there, but only a few have shown research results and those results don't tell the whole story." Smith recommends working with vendors who know about research results, not just sales.Presenters at the ErgoCon said that for individual companies, good ergonomics programs can save money in workers' compensation claims. Lou Freund, director of the Silicon Valley Ergonomics Institute at San Jose State University, estimates that the return on investment for an ergonomics program at a large company after five years will show a 15 percent return on investment. After 10 years, that return doubles. The returns are so high because workers' comp cases can mean not only payoffs but also hiring new workers with less experience.The problem, Freund says, is that companies with good ergonomics programs are not sharing the secrets of their success due to fears of competition. Government could carry that torch, disseminating information about good ergonomic practices which private companies are reluctant to share.Still, to say a program may work for a company doesn't mean regulation is a good idea. Skeptics about ergonomics regulation say that it is difficult to develop ergonomic solutions when the causes of ergonomic injury are uncertain. They warn that companies and state agencies may end up wasting money on untested furniture as they try to comply with the regulations.San Jose physician Jimenez encourages employers facing worker complaints to get their workplace evaluated for ergonomic problems by a physical therapist or an occupational therapist. But Jimenez says he opposes the ergonomic standards because they might encourage a one-size-fits-all approach."It's very difficult to legislate or regulate every little circumstance, especially with a dynamic process such as the living body," Jimenez says. "All humans are built differently, so it is hard to regulate set rules for everyone. For instance, to say that all computer operators had to have a forearm support of a certain type might not work for all body types."In 1993, the state Legislature passed a bill ordering Cal-OSHA to "develop a standard to reduce repetitive motion injuries in the workplace by January 1, 1995." It was a last-minute addition to the workers' compensation-reform package designed to crack down on fraud in the system -- apparently the product of a political compromise. Labor activists saw the bill as the bright lining in a dark cloud. "It was one of the few elements in the package that benefited the injured worker. It did something to prevent workers' comp cases in the first place," says Tom Rankin of the California Labor Federation.Cal-OSHA missed the deadline after a first attempt at regulations sparked a deluge of protest from both sides. Frustrated labor groups took the matter before a judge, which ordered the agency to adopt a standard by December of this year. Last December the board, composed of representatives from labor, business and medicine, released a watered-down version of their earlier standards. The new guidelines don't prescribe certain kinds of ergonomics furniture or assembly-line changes. Instead, they merely suggest voluntary, broad guidelines for an ergonomic program.Dr. David Rempel, a founder of the ergonomics program at UC-Berkeley, says he's frustrated that the standards do not require employees to try to prevent repetitive injuries. They only require an ergonomic program for workplaces in which at least two employees are already injured.Because the guidelines are so broad, they give employers the flexibility to decide for themselves -- or leave it up to each employee, as Silicon Graphics does -- what kind of workplace changes are needed to diminish the injuries. Ideally, that will let the company, and not the government, decide what works for them. There is a danger to such vague prescriptions, however: If an employee challenges your ergonomics program in court, a judge may end up picking your furniture.Meanwhile, the RSI support group in Palo Alto trades information about doctors, physical therapists, acupuncturists. Many have become frustrated with conventional medicine's solutions. The tai chi practitioner asks them to scan each others' wrists and hands with their open palms to feel the chi, or "energy," which emanates from their bodies. He claims that tai chi exercises and meditation will help produce a "positive net energy flow" and physical well-being.The group follows his instructions to the letter. Then, at the end of the lesson, they are enraptured by his slow, methodical dance. They will try anything to lessen the pain.How can a workplace injury become an epidemic?In the early 1960s, an epidemic of a "repetitive strain injury" called occupational cervicobrachial disorder broke out among telephonists at Nippon Telephone and Telegraph. Within three years, the number of cases reported shot up from about 100 to more than 3,000. Then, almost as quickly, the epidemic tapered off; by 1973, only 1,000 cases were reported.The telephone company credited the decline to new, lightweight headsets. But if heavy headsets were to blame, then why did Australia's state telephone company, which already used the light headsets, suffer its own epidemic starting in late 1983? And if keyboards were to blame, why was RSI an epidemic among telephonists -- who hit a few hundred keys an hour -- but rare among telegraphists -- who hit 12,000 keystrokes an hour?Even the most fervent believers that RSI is mostly caused by work admit that the problem seems to have a "contagious" quality. Reported symptoms may start with one worker at a workplace and then quickly spread. But if RSI is the physical result of workplace equipment or work habits, shouldn't it result in a steady stream of complaints rather than a jump and then a decline?Those who believe that RSI is usually work-related have an explanation for the contagion effect. They say workers learn through injured colleagues that the aches and pains they had long felt could have dire effects. Once they learn that their pain can escalate into a disabling injury, they are more likely to seek relief earlier. Eventually there is a decline in problems as companies adjust workplace ergonomics or workers learn new habits.Professor Lou Freund, director of the Silicon Valley Ergonomics Institute at San Jose State University, acknowledges that in the first two or three years of an ergonomics program companies will see more RSI-related workers' compensation cases, though those cases will be relatively mild and inexpensive. In companies that have stuck with ergonomic programs over the longer term, however, Freund has seen savings as employees learn safer work habits and use more ergonomic equipment.But physicians who are skeptical that physical work activity is the primary cause of RSI interpret contagion in a different way. "One view of the epidemic is that of a group hysterical reaction to widespread discomfort and a boring unsatisfying job, which was prompted by pressure from the media, managements, unions and the opportunity for compensation," wrote David Ferguson in the Medical Journal of Australia.Australia reacted to its RSI epidemic through a crackdown. The courts decided that worker's compensation won't be granted unless RSI sufferers can document physical injury, not just symptoms and a probable cause. The American Society for Surgery of the Hand applauded the decision.In Ferguson's view, the best solution to most symptoms under the RSI umbrella was not "rest and compensation" but treating fatigue, discomfort and anxiety within the workplace. Doctors should limit their diagnoses to physical findings and avoid diagnosing a syndrome -- a sometimes diffuse collection of symptoms which may imply physical injury when none can be observed. And as Dr. Graham Wright wrote in an article accompanying Ferguson's, patients with all forms of chronic pain are typically treated not through a command to stop activity entirely, but through a "graded return to activity under professional supervision."The engineer Freund and physician Ferguson do appear to agree on one important issue: Ferguson, a consultant to Australia's government work safety program, promotes "attention to ergonomics" as an important treatment for RSI symptoms.