WORK-RELATED injuries, long the plague of those who do heavy manual labor, have become a scourge among white-collar workers, too. Experts say hundreds of thousands of office workers are being disabled each year in an epidemic of motion-related damage to the hands and arms that is costing the nation many billions of dollars annually.
The problem is expected to worsen in the current recession as businesses demand greater output from fewer employees and workers ignore symptoms for fear of losing their jobs.
Over the last decade disorders caused by movements repeated many thousands of times a day, long a plague on assembly lines and in processing plants, have invaded the once low-risk environment of the office worker along with the computer. Computer operators spend many hours in the same position doing the same task without breaks or variation, giving no time for stressed tissues to recover. Over time, this behavior can induce crippling changes in the sensitive tissues of the wrist and hand.
High rates of injury have been reported among data entry workers, telephone operators and newspaper reporters and editors who work for many hours a day typing on a computer keyboard. At Newsday, the Long Island newspaper, for example, 40 percent of the writers and editors have reported often disabling symptoms of the hand and wrist that researchers say have been caused or made worse by excessive work on computers. Similar problems have occurred among newsroom workers at The Los Angeles Times, The Financial Times of London, The New York Times and Reuters, the news agency.
People with the disorders, which can sometimes be permanent, can find themselves unemployable or forced to change careers. Favorite sports activities, housework, carrying groceries, or even holding a coffee cup may become difficult or impossibly painful.
The disorders have many names — repetitive stress or repetitive motion injuries, cumulative trauma disorders, of which carpal tunnel syndrome is one, and most recently, work-related musculoskeletal disorders, the designation of the World Health Organization. But it all boils down to damage caused principally to tissues within the hand and arm by seemingly innocent actions that are repeated perhaps thousands of times each work day, like typing on a computer, cutting meat or poultry or etching glass. Some experts call it an overuse syndrome, the biological equivalent of metal fatigue.
“States report that 30 to 40 percent of workman’s compensation claims now result from musculoskeletal disorders,” said Dr. Roger Stephens, director of the Office of Ergonomics at the Occupational Safety and Health Administration in Washington. He predicted that without dramatic changes in equipment design and work habits, these problems would soon account for half of every dollar spent on such claims. Fast-Growing, Expensive Problem
While injuries to the back remain the nation’s most costly job-related hazard, damage to the wrist and hands is now the fastest growing category of worker’s compensation claims. The American Academy of Orthopedic Surgeons estimated in 1984 that the problem cost the nation more than $27 billion a year in lost wages and medical care, an amount that could well have doubled by now since there has been more than a doubling in reported cases.
Dr. Marvin J. Dainoff, a psychologist who is the director of the Center for Ergonomic Research at Miami University in Oxford, Ohio, has called repetitive stress injury the “occupational disease of the 90’s” similar to the asbestos crisis of the 1980’s. New companies have been formed to help workers cope. There are also several hand clinics springing up in hospitals around the country that try to rehabilitate injured workers.
At one, the Miller Health Care Institute at St. Luke’s-Roosevelt Medical Center in New York, 53 white-collar workers with severe injuries to their wrists and hands are being treated with rest, exercises to strengthen, stretch and relax structures in the arms and hands, and splints worn at night to keep the wrists straight. They were videotaped while working and taught new techniques to reduce the stress on their hands and wrists. And their work stations were adjusted to suit their individual needs.
“Those with problems that are caught early can expect to recover in a few months,” said Dr. Emil Pascarelli, director of ambulatory care at the hospital. “But workers with severe injuries can take a year or more to get better.”
In some parts of the country, workers diagnosed with carpal tunnel syndrome are often treated with surgery to reduce pressure on the nerve that is compressed by swollen or enlarged tissue passing through the wrist. While some surgeons say the procedure is remarkably helpful to 60 to 80 percent of patients, other experts say it is abused by doctors who do not try more conservative remedies first. Hand surgeons now perform an estimated 100,000 operations a year to cure carpal tunnel syndrome. Origins Are Ancient
The problem of work-related musculoskeletal disorders is not new. In 1717 the father of occupational medicine, an Italian doctor named Bernardino Ramazinni, first described cumulative microtrauma as a main cause of occupational disease.
But repetitive motion disorders received only a flicker of expert attention until they began striking white-collar workers and especially newspaper reporters, who had been all but immune to the job-related injuries that other laborers have endured for centuries. Some of the rise in cases is widely attributed to increased recognition of the problem and a new willingness to report it.
Dr. Laura Punnett, an ergonomist and epidemiologist at the University of Massachusetts at Lowell, said “historically there’s been lots of underreporting” of these disorders. As she explained, “Many workers did not recognize the problem as being job-related; others who did worried about losing their jobs if they reported their injuries.”
The Occupational Safety and Health Administration is only beginning to formulate regulations to curb these disorders, which continue to plague huge numbers of workers who process meat, poultry and fish and operate machinery, as well as those who use computers.
Dr. Barbara Silverstein, an epidemiologist with the Department of Labor and Industries in Washington State, noted that the United States is a Johnny-come-lately in trying to curb problems caused by repetitive motion in the workplace. In Japan, she said, a longstanding national commission has limited the time workers can spend at keyboards and set mandatory rest periods. The result, she said, has been fewer repetitive stress injuries among keyboard operators in Japan. Best Workers Suffer Most
A common experience of workers in America who report hand and wrist injuries to their employers is to find themselves suspected of malingering. Employers’ doubts are bolstered by the fact that victims of repetitive stress injury take longer to recover and are less likely to return to work if they have filed worker’s compensation claims, according to a study of 28,000 workers conducted by Dr. Gary Franklin, a neurologist who serves as medical director for Washington State’s Department of Labor and Industries.
Dr. Franklin also noted that the disabilities suffered by many workers were “out of proportion” to measurable abnormalities in their wrists, a widely acknowledged finding that has prompted Dr. Nortin M. Hadler, a rheumatologist at the University of North Carolina, to dispute whether the problem is real. Dr. Hadler maintains that musculoskeletal activity that is “reasonable, comfortable and customary and which can be repeated without undue distress,” such as typing on a computer, is unlikely to result in tissue damage.
Others, like Dr. Silverstein, report that although dissatisfied workers are prone to exaggerate their injuries or discomforts, she found in studying workers with problems at Newsday that the most devoted and talented reporters typically suffered the most.
“These are high-production people who don’t listen to their bodies,” Dr. Silverstein said. “They don’t stop working when they start hurting. The same with musicians. It is the high-performance people who are at highest risk of musculoskeletal disorders. And one could hardly accuse musicians of seeking to get paid without working, since they don’t.”
In a seven-industry study of factory workers, she also found no differences in overall job satisfaction and in views about work in general among employees afflicted with hand-wrist disorders and those who were not.
Still, she and Dr. Franklin agreed that psychological and social factors can make work-related muscular stress worse by increasing muscular tension. One complicating factor is being unable to modify the work schedule and pace of work to an individual’s need. Another is receiving too little support from one’s supervisor. A third is having an uncomfortable work environment.
Among the physical factors Dr. Dainoff lists as raising a worker’s risk of hand-wrist disorders are these:
*High rates of repetition of the same action. A computer operator who types 60 words a minute can make 18,000 keystrokes in an hour.
*Awkward or unnatural posture while working. The ideal position of the wrist is flat and straight, which positions the hand level with the arm and extended in a straight line from it. Those who work with hands bent up, down or to the side risk damage to the tissues in the wrist.
*Use of excessive force while working. In Dr. Silverstein’s factory study, workers who had to use high force and a high rate of repetition had 29 times the rate of hand-wrist disorders as workers using low force and a low rate of repetition.
*Lack of adequate rest periods or recovery time. Experts estimate that hands should be relieved of repetitive motion for at least 15 minutes every 2 hours to reduce the risk of injury. “Try telling that to a reporter writing against a deadline,” Dr. Silverstein remarked.
People who work on computers, which do not require much force to operate, may nonetheless fall victim to repetitive stress injuries. Dr. Dainoff explained that in many computer-reliant offices like newsrooms, almost every activity is done with the keyboard, including writing, editing, taking notes, searching for information and sending messages. In addition, there is no break to change paper or push a carriage return and no limit imposed by the machine on how fast one can type.
Some computer-based jobs are “the sweatshops of the 90’s,” said Dr. John Kella, a musician and biomechanic who directs a rehabilitation and retraining program for injured workers at the Miller Institute in New York. He pointed out that computer keyboards are unforgiving and many operators press the keys too hard, causing an almost imperceptible kickback as the fingertips hit the keyboard’s rock-hard bottom. Injuries Are Real
His colleague, Dr. Pascarelli, likened it to dancers performing day after day on a concrete floor. “Eventually, they are going to get injured,” he said.
The injuries that he treats are often not “classical” syndromes with readily identifiable pathological changes in structures of the hands and wrists. Some, perhaps a quarter of those complaining of symptoms, have clear cases of carpal tunnel syndrome. Some have tendinitis, an inflammation of the tendon that passes through the wrist, and others have tenosynovitis, an inflammation of the sheath around the tendon. But many fit no recognized classification.
Dr. Lawrence Fine, an occupational medicine specialist for the National Institute of Occupational Safety and Health in Cincinnati, said: “Yet these people are in a lot of pain and are forced to take time off from work. It’s hard for me as a physician to say it’s all in people’s heads, especially when the frequency and severity of the disorders abates when the risk factors are reduced.”
Even when a rational remedy is applied, the workplace setting can sometimes cause it to backfire. Dr. Silverstein gave on-the-job exercises to workers in a dental floss manufacturing plant. A year into the program she found no improvement in the rate of repetitive stress injuries because the workers, forced to meet production quotas, had worked harder to make up for the time lost during their exercise sessions.
Tomorrow in the Personal Health column: Early recognition, treatment and prevention of computer-related injuries.
Photo: Dr. Emil Pascarelli, director of ambulatory care at Miller Health Care Institute at St. Luke’s-Roosevelt Medical Center in Manhattan, teaching keyboard techniques to Kathy Giaimo, who has wrist injuries. Dr. John Kella recorded the session. Dr. Pascarelli says that injuries caught early can be cured in a few months. (Marilynn K. Yee/The New York Times) (pg. C10) Diagram: “Working Your Way to Pain” Repetitive motion injuries may occur when the same movement is done over and over for a long time. One of the most common is carpal tunnel syndrome. Tendons become inflamed and swollen, compressing a key nerve that also runs through the narrow carpal tunnel. The result is pain, numbness and tingling in the first three fingers and the base of the thumb. Finger movements are controlled by muscles in the forearm and transferred by long tendons in the top and bottom of the hand. The tendons, nerves and blood vessels all pass through a tunnel in the wrist, made of bone and ligament, called the carpal tunnel. (Sources: Dr. Marvin J. Dainoff; CIBA Collection of Medical Illustrations, CIBA-Geigy.) (pg. C1)