The sensible thing to do is prevent the pain

May 1, 1997
Repetitive motion disorders painfully chase many hygienists away from their occupation. Workplace illnesses, though, often can be controlled by focusing on something that sounds familiar to the profession - prevention.

Repetitive motion disorders painfully chase many hygienists away from their occupation. Workplace illnesses, though, often can be controlled by focusing on something that sounds familiar to the profession - prevention.

Frances Wolfe

When dental hygienist Lynn Carlson began experiencing stiffness, aching, and tingling in her wrists five years ago, then the subsequent loss of sensation in her fingers and hands, she realized she had an occupationally related problem and sought medical attention.

"It got so bad," she says, "I would wake up at night with my hands and wrists so sore that I wondered how I would be able to go into the office the next morning and do deep-scaling appointments."

Carlson (not her real name) tried a variety of physician-prescribed palliative treatments, including hand-stretching exercises, shaking her hands between patients, rotating her appointment schedule among easy and difficult cases, reducing her work schedule, taking vitamin B-6 supplements, taking over-the-counter anti-inflammatory medication, soaking her hands in hot water, and wearing wrist splints. Her condition, though, continued to deteriorate to the point that she had no alternative other than to undergo carpal tunnel surgery.

A delicate `tunnel`

Within a year, she had left private practice forever. "I simply couldn`t continue," she says. "The pain and inability to function at chairside to the best of my ability forced me to give up a profession I truly loved."

The positive side of this story is that Carlson went back to school, got her master`s degree, and today enjoys something she loves dearly: teaching hygiene in a four-year, university-based program. "I enjoy teaching," she says, "and I have incorporated into the curriculum information for our students on techniques they can use to avoid the pain and subsequent surgery I had to endure."

Anatomically, the median nerve travels from your shoulder down to your palm. It carries the senses of touch, temperature, and pain to your thumb, index and long fingers, and to part of your ring finger. As this nerve travels through the palm side of your wrist, it passes through a tunnel, formed by the wrist (carpal) bones, and a stout ligament called the carpal tunnel.

The tendons that move through the thumb and fingers also travel though this tunnel. Each tendon is surrounded by a membrane sheath (the synovial membrane), which lubricates the gliding and sliding motion of the tendon. Because the nerve is the most delicate and sensitive structure in the carpal tunnel, anything that injures or impinges upon it will cause abnormal sensations.

Dr. Donald Pfeifer, an orthopedic surgeon with the Dickerson Medical Group in Delaware explains, "Usually, these abnormal feelings are tingling, burning electric shock, painful `pins or needles,` or numbness." He adds that the feelings are the symptoms of median nerve compression and constitute carpal tunnel syndrome. While any kind of swelling - from a broken or dislocated wrist, to arthritis, to a hormonal or glandular condition associated with fluid retention - may cause or at least contribute to the nerve compression, "by far, the most common cause," says Pfeifer, "is overuse from repetitive and forceful grasping."

According to orthopedic surgeon Dr. Robert Markison, who practices in a large medical office 22 stories above downtown San Francisco, symptoms suffered by repetitive-strain injury (RSI) sufferers - including carpal tunnel syndrome - are the after-effects of static muscle-loading, which occurs when the muscles of the shoulders, legs, neck, or hands remain in a prolonged state of contraction.

"When these muscles are not periodically relaxed," says Dr. Markison, "circulation is decreased." He goes on to explain that nutrients carried in the blood are not supplied rapidly enough, while waste products - such as lactic acid - build up in the muscle tissues, causing soreness and pain in RSI-sufferers.

It`s not all in the wrist

According to Business Week, RSI disorders are "the fastest-growing occupational disease of the 1990s." RSI-reported cases already have topped 300,000 annually. Recent survey findings, conducted by CTD News of 3,000 U.S. and Canadian companies, estimate the average, direct cost of each cumulative trauma case (including wrist problems, carpal tunnel syndrome, and back injuries) was $3,720. When factoring in overtime, training, and production losses, cost more than tripled to at least $12,000 per case.

"Any time a job requires that you remain seated or standing in one position for any length of time, you`re at risk," says Carol Hall, president of women-owned Ergonomics Express: The Human Factor, in Tempe, Arizona. Hall works with therapists and ergonomists to develop preventive programs in the workplace before problems start, as well as to alleviate symptoms once they begin. She routinely conducts work-site assessments, evaluations, and recommendations with the assistance of ergonomists and therapists.

"There are chairs and stools with locking castors that help keep the worker stabilized," she says. "It`s also important for the hygienist to have some type of forward support." Ergonomics Express also designs custom, wrist-supports for those suffering from repetitive motion, cumulative trauma, and carpal tunnel symptoms.

What else can you do if you begin to experience the symptoms of CTS or RSI? Plenty! Several instrument-manufacturing companies have devoted time and resources listening to hygienists. They also employ hygienists as research advisers and regional sales representatives. Several things they have developed and incorporated into their instrument design include lighter, larger-diameter instruments, with knurled handles. The knurled handles require less gripping or squeezing, which reduces hand fatigue. Other experts suggest that switching instruments, with different diameters, throughout the day, helps ease CTS symptoms.

According to a company spokesperson of American Eagle in Missoula, Montana, "The advantage of a handle with aggressive grip is you don`t have to press as hard - there`s less hand fatigue. If you don`t have to put pressure on it, your hand isn`t going to get as tired." The bigger the handle, the better. All of the tests American Eagle conducted concluded that the lightness [of the instrument] improves tactile sensitivity.

One large U.S.-managed, dental health-care provider reports 10 percent of its dental employees out-of-work with hand problems. Switching to the knurled, lighter handle has helped lower their workers` comp claims. An orthopedic surgeon in Portland recommends the newer designs by saying, "This better grip is especially important when wearing OSHA-mandated gloves as part of the universal precautions set forth by the CDC."

According to a glove expert at SmartPractice, Phoenix, Arizona, switching from ambidextrous to left-right fitted gloves also may provide some relief for hygienists who experience day-end hand fatigue, associated with the muscles constantly having to work against the "tugging" force, as a result of wearing an ambidextrous glove.

One hygienist says, "Wearing an ambidextrous glove is like having 100 tiny rubberbands that your thumb is constantly pulling against. Working in the proper size of gloves, specifically fitted to my hands, makes all the difference in the world. And my productivity in the office has increased as well. Why not pay a few pennies more for a glove that really fits?"

Using the right handpiece will help alleviate some of the symptoms associated with CTS, as well. Your handpiece should be lightweight, compact, and easily grasped. Unbalanced handpieces, with the motor weight at the end, require a firmer grasp and increased extension of the wrist.

Ideally, your prophy angle should be short and contra-angled, rather than traditionally right-angled, to maintain a neutral wrist position and allow for easy access to all areas of the oral cavity. Some hygienists also have reported that switching from a prophy angle to a prophy jet-type, air-polishing system has helped alleviate symptoms of CTS.

The right handpiece cords also can help, because any device that causes resistance against the wrist and wrist extension should be avoided or better yet, replaced. The most common example is the retractable or curly-Q cords on the dental unit. The tension is transferred easily to your wrist, as the cords are stretched tighter. This can be especially harmful if your wrist is in a flexed position. Try replacing the cord with a straight cord of adequate length or, if possible, position the cord over your shoulder, to cut down on the stress concentrated on your wrist.

When online...

While most hygienists do not spend the majority of their work days at a computer terminal and keyboard, here are some tips that will help, if you have a computer terminal in your operatory:

- Make sure the top line of data on the computer screen is at your eye level. If it`s too low, raise up the computer or lower your chair.

- Always work with a wrist rest or padded bar. This gives you a place for your wrists while inputting data. Some people who work with computers throughout the day find the ergonomic keyboard a welcome relief from the flat, traditional type of keyboard.

- If your computer screen glares, add a filtering screen to reduce eye-fatigue.

In summary, there are lots of ergonomically-correct measures you can take to care for your body, to help prevent physical ailments associated with carpal tunnel syndrome, repetitive-stress injuries, and hand-fatigue. Taking care of yourself helps ensure a more comfortable, enjoyable, and extended career.

Frances Wolfe is a pen name for a long-time dental editor.

Treatments Curb Wrist Pain

Carlson`s history of work-related carpal tunnel and cumulative trauma injury is no isolated incidence in the work force. "By the year 2000, 60 percent of all work-related injuries will result from cumulative trauma disorders (CTDs)," says David Kaysen, president and CEO of Rehabilicare in New Brighton, Minn. Currently in the United States, the market for treatment of CTD injuries exceeds $11 billion annually.

Kaysen, whose wife is a hygienist, recently introduced a new, electronic-therapy system, designed specifically to treat wrist pain associated with repetitive stress.

"Carpal tunnel surgery can run about $30,000, which comes after the employee has tried work-duty restrictions, time off, and medications, ranging from over-the-counter pain-relievers to steroid or cortisone injections into the wrist," says Kaysen. Compare that to a treatment regimen that lasts about two months and costs on average $600.

The Rehabilicare CTDx is a wrist splint attached to a power supply. During work breaks or between patients, the dental health-care worker with wrist pain slips on the brace and the power supply delivers therapeutic, electronic charges. Four disposable electrodes attach to different parts of the wrist and to an electrical stimulator that uses a combination of positive and negative charges to speed blood circulation.

"The result," says Kaysen, "is the increased blood circulation that reduces swelling and lowers the pain."

Kaysen stresses that the CTDx is not a cure for acute RSI, but treats the early symptoms to improve circulation and prevent further damage. Employers and their compensation-benefits administrators love the concept, because it saves lost time from work, the expense, and recuperation period associated with surgery.

From an economical standpoint, employers are looking for a cost-effective treatment regimen that allows the employee to continue to work comfortably without pain or numbness, as well as without waking up at night because of intense wrist pain.

Double-blind studies indicate that the CTDx electrostimulation system is likely to reduce pain and swelling and increase localized fluid flow in the wrist area, and to improve motor-nerve conduction through the carpal tunnel.

Subjects in a recently completed study were randomly assigned to either a group using Rehabilicare`s CTDx System, with its proprietary wrist splint and electrode system, or a group using a placebo-stimulator and wrist splint. To date, current data on 90 patients has been compiled, comparing the baseline motor-nerve conduction measurement to motor-nerve measurements after 30 days of on-the-job treatment sessions. Seventy-seven percent of the 47 patients using the CTDx System showed improvement in motor-nerve conduction measurement; of the 43 patients using the placebo system, only 26 percent showed improvement.

According to Susan Stralka, MS, PT, director of physical therapy at the Campbell Clinic in Memphis, Tenn., who conducted the studies, "The CTDx System has been extremely well-received by the participants in this study."

She adds that it was easy to use. Most participants underwent treatments during their lunch breaks. She also notes that subjective data from the participants indicated "significant reduction of pain, ability to stay at work longer, and sleeping through the night once again."

A nonsurgical alternative

Suffering from CTS symptoms and looking for an option to surgery? A deep-massage technique, called myofascial release, offers hope to hygienists wanting to avoid surgery.

"Once the body tissues are cut, they`re cut forever," says Carole Wile, a licensed massage therapist and nutritionist with Therapy on the Rocks, Myofascial Release Treatment Center. "Today, there are alternative, deep-massage therapy techniques we can use to help the majority of dental hygienists who suffer from CTS to avoid surgery."

Chief physical therapist Brenda S. Barkeloo, also of Therapy on the Rocks, says, "When treating hygienists for carpal tunnel syndrome, we treat not just the affected hand and arm, but also the thoracic inlet and the rib cage."

She adds that hygienists often are not necessarily taught exercises or stretches to reduce the ill effects of performing repetitive motions. "Hygienists can benefit from specific exercises and self-treatment techniques by learning how to open up the affected muscles surrounding tissue," Barkeloo says.

Fascia, a tough, connective tissue, which is spread throughout the body in a three-dimensional web, connects the wrist to the arm and the rest of the body. "Tensions from the body also can be transmitted down to the arm and wrist, slowing healing," she says.

Barkeloo adds that, with a doctor`s prescription or direction, many hygienists who have health insurance may be covered for this form of deep-massage therapy.

(1) Your handpiece should be lightweight, compact, and easily grasped. Unbalanced handpieces, with the motor weight at the end, require a firmer grasp and increased extension of the wrist.

(2) Your prophy angle should be short and contra-angled, rather than traditionally right-angled, to maintain a neutral wrist position and allow for easy access to all areas of the oral cavity.

(3) The right handpiece cords also can help, because any device that causes resistance against the wrist and wrist extension should be avoided or, better yet, replaced.