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Still discussing why reports of RSI are in decline …

“Can a workplace epidemic be cured?

With the personal computing boom of the 1990s came thousands of “repetitive stress injuries” or “repetitive strain injuries.” RSI became the hip medical acronym of the keyboard era, with subset carpal tunnel syndrome the diagnosis of the day.

“At its height of diagnosis, anybody showing up at a doctor’s office with wrist pain or hand pain was being diagnosed with carpal tunnel,” said Carol Harnett, vice president of insurer Hartford Financial Services Group’s group benefits division.

Since then, carpal tunnel cases have plummeted, declining 21 percent in 2006 alone, according to the Bureau of Labor Statistics. Among workers in professional and business services, the number of carpal tunnel syndrome cases fell by half between 2005 and 2006.

What changed?

First, it may not have been the white-collar epidemic it appeared to be.

A 2001 study by the Mayo Clinic found heavy computer users (up to seven hours a day) had the same rate of carpal tunnel as the general population. Harvard University headlined a 2005 news release: Computer use deleted as carpal tunnel syndrome cause.

“Clearly, if keyboarding activities were a significant risk for carpal tunnel, we should have seen, over the last 10 to 15 years, an explosion of cases,” said Dr. Kurt Hegmann, director, the Rocky Mountain Center for Occupational & Environmental Health. “If keyboarding were a risk, it cannot be a strong factor.”

Blue-collar workers, especially those doing assembly line work such as sewing, cleaning and meat or poultry packing, have a far greater incidence of carpal tunnel than white-collar workers, according to Bureau of Labor Statistics data.

RSI label dropped
That doesn’t mean white-collar workers don’t get carpal tunnel and related disorders. But it may mean such disorders were overdiagnosed when they were most in the news, resulting in an artificially high number of cases by the late 1990s. Most doctors have dropped the term RSI, calling them “musculoskeletal disorders” while government agencies like “cumulative trauma disorders.”

Now, some experts think some of those patients had “referred pain” from trouble elsewhere, such as the neck. Other theories claim attention to ergonomics has prevented injuries, or that they have become underreported because they lack the immediacy of a broken bone.

People who’ve had a cumulative trauma disorder say it can be debilitating. Clay Scott, now an assistant professor of electrical engineering and computer science at the University of Michigan, developed severe wrist pain during college at Harvard University. By the end of his senior year, he said he was incapable of doing daily tasks, such as cutting food and opening doors.

His recovery started with physical therapy a few times a week and a home exercise program to stretch and strengthen his back and neck muscles. It took three or four years for him to recover, he said.

Stopping it before it starts
Some businesses have been focusing on prevention, part of a growing effort by employers to keep their workers healthy.

Outdoor clothing company L.L. Bean shuts down its manufacturing line three times a day for mandatory five-minute stretches. Retailer Replacements Ltd. also runs on-the-clock group stretches as well as a fitness-walking program.

Blue Cross Blue Shield of Kansas started a program in 1991, when costs of the injuries to its employees passed $500,000. It bought ergonomic chairs and desks, introduced ergonomic assessments for new employees during their first two weeks of work and hired two full-time registered nurses to work with employees.

Since the program started, the company’s workers’ compensation costs have fallen by 62 percent, said Terri Janda, a nurse who leads the Blue Cross program.”    (Continued via Houston Chronicle)    [Ergonomics Resources]

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U.S. News & World Report ranked Arcadia University’s Physical Therapy program 7th in the nation among the more than 200 graduate PT programs. “This new ranking reflects on the quality of our faculty and the students in the physical therapist program! It means so much to me that the vibrancy, intellectual capacity and hard work of our faculty members were recognized by our peers,” says Dr. Rebecca L Craik, Professor and Chair of the Department of Physical Therapy.

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Boxing is possibly less dangerous for the brain than previously feared - at least for amateurs. However, conclusive statements on the level of danger are not yet possible. Whether professional boxers such as Muhammad Ali contracted their later brain conditions - in his case Parkinson’s disease at the age of 40 - presumably from boxing, remains unclear.

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Tate AR, McClure PW, Kareha S, Irwin D The objective of this study was to determine whether manually repositioning the scapula using the Scapula Reposition Test (SRT) reduces pain and increases shoulder elevation strength in athletes with and without positive… (Source: Physiospot - Musculoskeletal)

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Jan MH, Tang PF, Lin JJ, Tseng SC, Lin YF, Lin DH The objective of this study was to investigate the efficacy of high, repetitive, target-matching foot-stepping exercise (TMFSE) performed in a sitting position on proprioception, functional score, and walking… (Source: Physiospot - Musculoskeletal)

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I recently listened to a spirited debate on the PT Journal Podcast regarding two approaches to classification and manipulation for LBP. I strongly encourage you to download the file or subscribe to the podcast and listen for yourself. The debaters Timothy Flynn, PT PhD, OCS, FAAOMPT, and Christopher Maher, PT, PhD brought out some very salient points regarding the assessment and treatment of mechanical low back pain.

To be honest, I had to listen to the debate multiple times to pick out some of the really strong take-home messages that emerged from the discussion. While the debate was focused on the assessment and management of LBP, it had me thinking more rigorously about how these themes could apply to other aspect to our practice. In no particular order of importance:

• The widespread use of the term “nonspecific” low back pain is inadequate and misleading. It would be analogous to our medical colleagues using the words “nonspecific” abdominal pain and contributes to further confusion regarding accurate diagnosis and management.

• There is a need to develop standardized clinical practice patterns and a unified language with respect to the dosage and modes of manual therapy we deliver to our patients.

• There is still considerable variation between highly trained individuals regarding the classification, assessment, and management of mechanical low-back pain.

You can download the link by right-clicking here and saving to your hard drive.

I hope you will download this debate and continue to reevaluate your methodology with respect to evaluation and management of not only low back pain, but other complex conditions as well. Our aim as orthopedic therapists should be to continually elevate our standards of practice. Take care and talk to you soon!

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I sometimes wonder how ticked off I should be getting when I hear some of the things traditional or “straight” chiropractors tell their patients. It’s hard for me to challenge straight chiros on the grounds of their manual skill set, but should we really be content with allowing another profession to perpetuate the myth that is the subluxation theory?

I know the chiropractic profession is in serious crisis across the country, and sometimes feel I’m kicking an opponent when he’s down. However, for the sake of our profession and our patients, I feel obligated to be honest with my patients regarding my opposition to traditional chiropractic. I do feel better in the sense that I don’t sound like a evangelical minister anymore when I give these talks to patients. I’m able to present an opposing view to straight chiropractic in a more calm and objective (to me at least) manner.

Orthopedic physical therapists will continue to be at the forefront of rational approaches to the conservative management of musculoskeletal disorders. We need to make sure we are ready to do what it takes to defend our profession, but also be willing to put ourselves out there and take the offensive against quackery. The end result will be better health for our patients and our profession!

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Most therapists I’ve run into are pretty solid critical thinkers, capable of examining things from a variety of perspectives before jumping headlong into shallow water. Unfortunately, there is a not-too-silent minority of our community that continues to grasp at methods of assessment and treatment that not only aren’t consistent with available evidence, they are in direct conflict with the laws of nature and just plain common sense!

I always look forward to a great debate like the one mentioned in an earlier post, but enjoy participating in one even more! The trouble is I find myself often reducing my argument to the level of “Because my view just makes more sense than yours” reasoning that simply doesn’t wash with most people. This kind of logic, among others, often irritates and sometimes insults otherwise well-meaning (albeit misinformed) individuals.

Wouldn’t you know it but there are actually rules of engagement that can help you get your point across without alienating your fellow coworker or boss. They are brought to us by the late scientist Carl Sagan who offers his criteria for solidifying your logic.

1. Wherever possible there must be independent confirmation of the facts.
2. Encourage substantive debate on the evidence by knowledgeable proponents of all points of view. Arguments from authority carry little weight (in science there are no “authorities”).
3. Spin more than one hypothesis - don’t simply run with the first idea that caught your fancy.
4. Try not to get overly attached to a hypothesis just because it’s yours.
5. Quantify, wherever possible.
6. If there is a chain of argument every link in the chain must work.
7. “Occam’s razor” - if there are two hypothesis that explain the data equally well choose the simpler.
8. Ask whether the hypothesis can, at least in principle, be falsified (shown to be false by some unambiguous test). In other words, it is testable? Can others duplicate the experiment and get the same result?

There is certainly a sense of balance we can achieve with respect to our pursuit of gold standards of assessment and treatment. In fact, one of my favorite instructors stated “Nothing is ever proven; only supported.”

Here are some questions to ponder the next time you face an argument over a clinical issue: Can you be an evidence-based practitioner without becoming an automaton? Conversely, can you explore creative treatment options without becoming a faith healer? This is an exciting time for our profession. Keep honing your skills and take a critical look at your approach to clinical problems. You may not be the next Carl Sagan, but the exercise will sure do us some good!

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