Erogonomics Revisited: Carpal Tunnel Syndrome

This article is about making sure that our workplace and work of the day is as safe and ergonomically sound as possible, so that we can stay healthy and do our work. It is important to periodically revisit and update the information on workplace ergonomics and identify the injuries we are seeing with increasing frequency in the lab. Repetitive-use injury, overuse injury, and musculo-skeletal overuse syndromes are all terms used to identify injuries seen in the workplace. Is back pain and injury the only overuse injury in the cath lab? This year at our hospital, another of our experienced staff had to make the choice between the field she loved, and the risk of permanent, perhaps crippling injury. It is time to revisit the physical demands of our job in the cath lab, and look to the ergonomic solutions we can develop. The story is repeated in health care occupations across the spectrum.¹ Repetitive work-related musculo-skeletal injuries are a major source of our medical care costs in the United States. These injuries are, according to the U.S. Department of Labor, the nation’s most common and costly occupational health problem, affecting hundreds of thousands of American workers, and costing more than $20 billion a year in workers’ compensation.² After feeling the tingling, then pain, in her arm develop and increase over weeks, our staff member sought help. Her physician diagnosed carpal tunnel syndrome, and sent her for a round of physical therapy. Her next round of treatment was to have a surgeon evaluate the injury, take her off duty for two weeks, wear wrist braces, and consider surgical intervention if her symptoms didn’t resolve. She returned to work on light duty, circulating in the lab, unable to scrub or make sterile tables without the pain returning. She felt frightened about the real possibility of surgical intervention. The other role in the lab, that of monitor, required data entry, and using a computer was also painful. At this point, she began to feel alone, unable to do her job, and wondering if others felt she was not pulling her weight. This story is a true one, and one frequently repeated in our world of interventional laboratories. Perhaps it is also repeated in our recovery areas, or with whoever is responsible for pulling sheaths, although it is not specific to our field. Office workers use computers most of the day and are susceptible. Also, ultrasound technologists³ and even assembly line operators, who repeat the same activity, against a force, over and over all day, develop carpal tunnel injuries. In articles found during a search of the internet at www.repetitive-strain.com, statistics from the Occupational Safety and Health Administration (OSHA) surfaced over and over again. The statistics are frightening, and a few important ones should be mentioned: 1. Annual cost to workers compensation is more than 20 billion dollars. 2. According to the Bureau of Labor Statistics, nearly 2/3 of all occupational illnesses were caused by repetitive-use injury to wrist, elbow or shoulder, with carpal tunnel syndrome being the chief occupational hazard of the 1990’s. 3. 849,000 new cases of carpal tunnel syndrome occurred in 1994. Currently this injury affects over 8 million Americans, and is the number-one reported medical problem, accounting for 50% of all work-related injuries. 4. 36% of victims require unlimited medical treatment. 5. Surgery for carpal tunnel syndrome is the second most common type of surgery, accounting for 230,000 procedures annually. 6. Only 23% of all carpal tunnel syndrome patients were able to return to their previous professions following surgery. These statistics and the injury patterns in the other fields are documented at the Department of Labor, OSHA, and NIOSH (part of the research arm of the Center for Disease Control). The statistics showed that worker motion or position accounted for 99.6% of all carpal tunnel injuries reported during the study period.⁴ The repetitive nature of the job accounted for 98.8% of reported carpal tunnel injuries. As simple as that sounds, it is that simple. The body is designed for working, muscle works best when worked, and that is basic anatomy and physiology. The limitation of all things is overuse. Overuse syndromes develop when the engine (the muscle) is not allowed adequate rest and recovery between periods of use. Athletes use this basic concept of work-rest-work, and they know that to develop muscles without tearing and permanent injury, they must rest. Our body has many compensating systems. The basic concept of ventricular hypertrophy and the stretching of the muscle until it fails is the concept behind Frank Starlings’ law: increased venous return results in increased stroke volume. As more blood enters the heart, more is pumped out by the heart. This law is clear and easily understood by all who study biology, anatomy and physiology. In the cath lab setting, we can use this analogy to understand the development of carpal tunnel injury, identify specific evaluation tools to understand the practices in our field, and then develop preventative and protective practices to protect our workers.⁵ Help from the Experts We have spoken with Clair C. Caruso, PhD, RN, and YongKu Kong, PhD, research scientists at NIOSH, and asked for their assistance in identifying ergonomic issues in the cath lab at Washington Adventist Hospital. (Note: The pronoun we refers to the assistance of my colleague and friend Gary Orr, Register red Ergonomist, and founder of Ergotonic, Inc. I have worked with him identifying the ergonomic concerns of using a computer for prolonged didactic training in our Cardiovascular Orientation Programs.) The mission at NIOSH is to identify and research potential or real hazards in the American workplace. Dr. Caruso and Dr. Kong are very interested in helping identify the risk of carpal tunnel injury to cath lab staff, and have the tools and scientists in place. These scientists will evaluate and analyze while we work. We are then able to concentrate on taking care of our patients. It is collaborative practice at its best! Dr. Kong has worked with a glove that measures the actual force needed to complete a task, such as holding manual pressure when recovering the arterial puncture site. We will actually be able to measure how much force is needed, then accumulate the numbers according to the number of times each staff holds a groin. In our cath lab, we hold groins and also have recovery areas with staff that hold groins, as well as staff that go to the nursing units to pull sheaths. This practice is repeated daily, over and over again. I wonder if physicians and fellows who also pull sheaths and recover groins have noticed their hands trembling, weakness in their grips, or pain after a day’s work. I have seen this in the lab, and we massage each other’s hands when we can. It relieves the pain on an immediate level, but I think a scientific look into this practice is warranted. It is not only a nice thing to do it is a mandated nice thing to do. Healthy People 2010, a Department of Health and Human Resources initiative, has as its goal the promotion of the health and safety of people at work through prevention and early intervention (www.healthypeople.gov).⁶ Published in 2000, this proactive paper outlined the government’s concern that many of our workers are being hurt by simply doing their work. It is now up to us to find ways of making the workplace safer. In presenting this potential collaboration between NIOSH and the cath lab to the hospital, the questions raised were primarily time-focused. The IRB asked who was to collect and manage the data, and then ultimately who owned the information. As we begin our work with NIOSH at Washington Adventist Hospital, we will work out the answers to these questions. Enter the Rest of the Invasive Team and Their Concerns The physicians we work with are also concerned with the injuries we see in the lab. Their concern is focused on back pain and injuries, and the Society of Cardiovascular Angiography & Interventions (SCA&I) recently presented a survey that asked the members if they have had significant back pain from wearing lead aprons. Following is an excerpt from a press release from the SCA&I website: Poor Ergonomics Takes Heavy Toll After Years in the Cath Lab (BETHESDA, MD, November 22, 2004) Imagine standing all day weighed down by 10 pounds of lead while craning the neck at an odd angle. That’s what interventional cardiologists do during coronary procedures, and it’s taking a heavy physical toll, according to a report in the December 2004 issue of Catheterization and Cardiovascular Interventions: Journal of the Society for Cardiovascular Angiography and Interventions. In a web-based survey of more than 400 members of the Society for Cardiovascular Angiography and Interventions (SCAI), 42 percent reported experiencing spine problems. Of these, 70 percent reported pain or injury to the lower back, and 30 percent to the neck. It’s no wonder, considering a typical 12-hour day in the catheterization laboratory, said Dr. James A. Goldstein, who headed up the survey and is director of Cardiovascular Research and Education at William Beaumont Hospital in Royal Oak, Mich. More than one-third of those who responded to the survey reported that spine problems had forced them to miss work. Nearly 30 percent of survey participants also reported hip, knee, or ankle problems. The likelihood of experiencing an orthopedic injury was directly related to the number of years an interventional cardiologist had been in practice. Just over one-quarter of those with less than five years of experience reported spine problems. Among those who had been performing invasive procedures for 21 or more years, however, the rate of spine problems was 60 percent. We’ve all known colleagues who have had to miss work or even give up interventional cardiology entirely because of back problems, but this is the first time we could put numbers to the problem, said Dr. Lloyd W. Klein, who chairs the SCAI Interventional Committee and is director of Clinical Cardiology Associates at Gottlieb Memorial Hospital in Melrose Park, Ill. These data tell us that this really must be a priority for our profession to understand better. Until now, the potential for orthopedic problems has largely been ignored, Dr. Goldstein said. We will be looking at it seriously to see how we can begin to reduce this potentially devastating complication.⁷ The next survey from the SCA&I will expand to include the injury patterns seen in the upper extremities. Background As noted previously, this article hopes to develop is a proactive approach to the identification and prevention of practices that can potentially harm our employees in the cath labs. I originally wrote articles and teaching sessions on the topic of Ergonomics in the Cath Lab a few years ago, and the research I did at that time took me to lectures presented by Lt. Col Mary Laedetke, OTR, PhD. then assigned to Aberdeen, Maryland. Her statistics on the cost of care of just one person with a carpal tunnel injury were stunning enough to me that I started looking deeper. At that time, in 1995, the cost of recovering one patient with carpal tunnel syndrome was around $35,000. My research led me to the Department of Labor and their meetings on ergonomics. I looked further, to the Department of Health and Human Resources, which had just published the Healthy People 2010 mandate to bring the citizens of the U.S. up a collective level in their personal health status. (Note the word mandate, which means it was the U.S. government that identified these health care issues as ones we must correct.) In Healthy People 2010, ergonomics and work-related illnesses and injuries were listed under the Category of Diseases and Injury, with a NORA Priority Research Area (NORA stands for National Occupational Research Agenda, and is put out by NIOSH). The last three items of an eight-item column were low back disorders, musculoskeletal disorders of the upper extremities and traumatic injuries.8 Sounds like carpal tunnel would fit right in that list, doesn’t it? B>Anatomy Lesson: Where is the carpal tunnel?⁹ Carpal Tunnel: A passage in the wrist through which the median nerve and tendons travel to the hand. Much of it is located at the base of the palm (Figure 1). Carpal Tunnel Syndrome: Pressure or compression on the medial nerve that may cause pain, numbness, weakness, etc.¹⁰ (Figure 2). Before the staff can identify if there is a reason for concern about pain, you must first identify what causes the pain, and if there is any treatment, or modification to the workplace to decrease the potential for further injury. This is the basis for the Healthy People 2010 mandate.¹¹ Let’s identify the causes of repetitive use injuries: Awkward Postures Most awkward postures in the wrist are seen whenever the wrist is out of a neutral position, and damage can occur when this posture is intensified by adding force to maintain it, or repeating the task too many times before recovery periods are allowed (Figure 3). This is where the terms repetitive and cumulative trauma are used to identify health hazards and risks. Tasks and Areas of Concern that May Further Injury Basically, there are at least two things we do repeatedly in the cath lab that can potentially cause carpal tunnel injury and syndrome. 1. Injecting contrast; 2. Manually holding groins for sheath removal. Injecting Contrast Injecting syrupy contrast against the systolic pressure in the arterial system is how we see the vessels. There is a degree of sensitivity needed to push with the right amount of force to replace the blood with contrast, and cath lab personnel do this 10-20-100 times each and every case. The numbers vary, depending on the procedure. However, if you add the number of times you just test, and the numbers of times you inject, the numbers are cumulative. There is a system available to inject in a programmable format, called the ACIST Device (Figure 5, ACIST Medical Systems, Inc., A Bracco Company, Eden Prairie, MN). It was developed to decrease the potential of cumulative or repetitive use injuries resulting from injecting contrast. Closure Devices, Compression Systems, and Groin Clamps There are many vascular recovery systems on the market today. They vary among intra-arterial, suture-mediated, extravascular, and topical pads that have substances impregnated in the bandage. C-clamps (or as one of our patients called it, the groin vice) have been around for years. The use of this clamp to hold pressure on the access site is uncomfortable at best, and requires direct and constant observation to allow the safest recovery of the patient. (If you are not familiar with this system, picture a big C with a big flat bottom panel. Now picture the patient between the top of the C and the mattress, and the flat panel on the bottom of the C under the mattress. The patient is clamped in-between, with a mushroom disk over the arterial site to hold pressure. The mushroom disk was developed to relieve the point surface pressure, radiating the pressure over the 3-inch disk.) The use of compression and belt systems to recover arterial access sites are available from manufacturers such as Radi, which offers the FemoStop® (Wilmington, MA) groin system, and their newer addition for radial access recovery, the RadiStop® compression device. Figures 6-7, provided by Radi Medical Systems, Inc., shows not only the system, but the recovery times needed for the patient and staff. This system is more comfortable for the patient than a C-clamp, since it does not require the access site to be clamped between a mushroom disk and the bed, with the patient in the middle. Radi has also developed a radial compression device to recover radial access sites, the RadiStop. The caveat here is that all compression and clamp devices require direct staff observation. It is possible that complications can occur, hematomas can develop, and these can be missed if the staff is pulled to another patient during the recovering process. Closure Devices and Hemostasis Discussions, but Ergonomics is Not Included There were many discussions and papers on closure devices and manual compression this past year. I went to three different sessions at the TCT 2004 meeting that discussed complications and the use of closure devices. The focus, however, was on complications and proper access techniques, and proper preparation of the access site. At the 2004 Cath Lab Digest Annual Symposium on Cardiovascular Care (ASOCC), there were two sessions that focused on vascular access recovery techniques. Michael Guiry, RPA-C, Lenox Hill Hospital, New York, compared manual compression to closure devices, and concluded manual compression was better for the patient. Dr. David Allie, from the Cardiovascular Institute of the South in Layfayette, LA, is a vascular surgeon who also works in the cath lab (that in itself drew me to his lecture at ASOCC). He presented an eye-opening session on vascular complications, noting that there is no perfect closure device, that all require learning new skills, and all have potential and real complications that need additional healthcare resources. Dr. Allie discussed the use of manual compression and noted that the technique was described by Dr. Sellinger in 1952. It was the gold standard then, and remains the gold standard still. In his follow up Cath Lab Digest article on vascular closure devices, he asked, Why in the world do we still have today, truthfully, such a gross procedure as manual compression as our gold standard for vascular access management?¹² In other words, is and should manual compression for vascular recovery be considered the best way to recover access sites? I also looked back through cath lab spotlight articles in Cath Lab Digest. The question is asked of each facility: How do you handle hemostasis? However, none of the authors mention if they noticed an increase in staff work-related musculoskeletal injuries, and used this as one consideration for implementing appropriate use of closure or compression devices to recover vascular access sites. Conclusion There have been many articles and presentations in the past year discussing and comparing vascular access site recovery techniques. The focus of these sessions was complication rates, patient satisfaction rates and surveys, and costs to the healthcare provider. Yet there was no mention of staff developing carpal tunnel injuries from the repetitive nature of the tasks we do to recover these patients. I find this fascinating. If you just look at our jobs, and the repetitive nature of some of our tasks, how we manage to keep our staff from developing overuse injuries begs for an analysis of the workplace. If we have a solution, we need to identify it, and share it with the rest of the world. If we have a problem, we need to identify it, find a way to fix it, and then share the solution with the rest of the world. Our field is growing. Our need for staff is increasing. The amount of patients we see each year is increasing. The concern for patient comfort and safety is a vital component of total patient care. The need to maintain a safe and healthy workplace for our staff is vital for good business. I do not think these statements are diametrically opposed, but are components of our job. The author would like to thank Gary Orr, Claire Caruso, YongKu Kong, Cathy Colombo, and all of the staff and editorial personnel who helped collect this information, and organize it into a palatable format. Marsha Holton can be contacted at MarshaSICP@aol.com

1. Injury Standards for the Prevention of Work-Related Musculo-Skeletal Disorders in Sonography. Society of Diagnostic Medical Sonography, May 2003.

2. National Statistics for Carpal Tunnel Syndrome. Balance Systems, Inc. Advanced Research in Rehabilitation Technology. Copyright 1996-2002, Balance Systems, Inc. All rights reserved. Pages 1-3.

3. Industry Standards for the Prevention of Work-Related Musculoskeletal Disorders in Sonography. The Society of Medical Sonography, 2003.

4. Bureau of Labor Statistics, U.S. Department of Labor, March 2004.

5. National Institute for Occupational Safety and Health, Health Hazard Evaluation Program.

6. Healthy People 2010, Section 20, Occupational Safety and Health. Pages 20-23.

7. Survey Finds Interventional Cardiologists Suffer High Rate of Orthopedic Injuries.” From www.scai.org (press room), November 22, 2004.

8. NIOSH National Occupational Research Agenda, Pub. No. 96-115. Cinncinati, Ohio, NIOSH 1996.

9. Holton M. Ergonomics. Cath Lab Digest Regional Meetings 2002.

10. What is Repetitive Strain Injury (RSI) and Carpal Tunnel Syndrome (CTS)? www.thehelpinghand.com, pages 1-4.

11. Healthy People 2010, Section 20. Occupational Safety and Health. Lead Agency: Centers for Disease Control and Prevention. Page 20.

12. Allie D. Vascular Access Hemostasis: An Endovascular Surgeon’s Perspective. Manual Compression May Not Be Benign. Cath Lab Digest Sept 2004;12(9):1, 6-14.