Trina Lee is an Australian-trained physiotherapist with a Bachelor of Applied Sciences in physiotherapy from the University of South Australia in Adelaide. She is registered in Australia and the USA, a member of the Private Practice section of the Singapore Physiotherapy Association and certified as Ergonomic Assessment Specialist. One of her aims as a physiotherapist is to promote awareness of good health and posture, safe movements and injury prevention both in the workplace and in sports.
Here
are two case studies, demonstrating the effects and consequences of Cumulative
Trauma Injury on a person's life and livelihood. Cumulative Trauma Injury ('CTI')
occurs in any part of the body which is subjected to prolonged or awkward
postures, repetitive motion or activities requiring excessive force or pressure.
Besides the following examples, other common cases of CTI include eye strain,
tension headaches, neck pain, elbow pain, shoulder tendinitis and heel pain.
These two cases, one about a lawyer with back pain and the other a legal
secretary with
forearm, wrist and finger pain can happen to anyone subject to similar work
stresses. Let us follow the development of their symptoms, the predisposing
factors and how the symptoms could have been prevented if the appropriate action
was taken at the right time.
Case Study 1 - Lawyer
Mr Lim has been working as a lawyer in a reputable firm for five years. He would often spend 12-hour days or longer sitting at his desk. The workload was so heavy, he barely had time to take breaks. Recently, he has had to take it easy due to his back pain and is having physiotherapy treatment three times a week. He has had to take sick leave for two weeks as the back pain became too unbearable
Early symptoms - minor disc bulge
Mr Lim had occasionally experienced mild discomfort in his back for a few years now, but was too busy to take notice and merely shrugged it off as due to working long hours. His back felt stiff in the morning and usually ached after a long day of sitting. He used to swim and work out in the gym but has now stopped and feels that he is putting on weight.
Management & outcome
At this early stage, Mr Lim would have benefited from placing a lumbar support in the small of his back to maintain the arch of his lower back and thus reduce the compression forces on his vertebral discs. He could have been aware of the cumulative stress of long hours of uninterrupted sitting and gotten up regularly to walk around, stretch his spine backwards or do other non-sitting tasks every hour just to ease tension off the spinal ligaments, discs and joints. If he had listened to the 'complaints' of his body and kept in shape, he would not only have kept his weight down but also maintained adequate spinal flexibility and strengthened the abdominal and back muscles which are essential in supporting and protecting the spine. These simple steps would have completely relieved the back pain and stiffness thereby preventing any worsening of the condition. In this case, the excessive sitting caused a mild bulging in the disc which is very similar to what happens to a water-filled balloon when sat on gently.
Moderate disc bulge
Mr Lim's back pain was getting worse. It was painful and stiff after sitting for two hours and he could feel some pain spreading down the left buttock. According to him, it was not severe enough to seek treatment and anyway, work was too hectic to take leave to see the doctor.
Management & outcome
At this stage, the disc bulge in the lower part of Mr Lim's spine was worsening to the point that it was putting pressure on pain-sensitive ligaments thus causing the referred pain to his buttock. If he had sought physiotherapy treatment to reduce the bulge and strengthen the supporting muscles of his back, the disc would have been contained and would not have worsened to the next stage.
Complete disc herniation
Two weeks ago, Mr Lim was bending down to pick something up and sneezed hard. Suddenly, there was sharp shooting pain in his back and down his left leg and he was unable to get up from the floor. He was sent immediately to hospital and, while in bed, underwent traction (a contraption which exerts a pulling force on the pelvis to release disc pressure) for a week.
Management & outcome
Now he has to undergo physiotherapy for regular traction, heat, mobilisations to loosen up the stiff joints and back conditioning exercises. He had let the situation get to the point that the fibres containing the disc ruptured, spilling out the inner gel-like material; similar to a water-filled balloon bursting. The result is that the nerve leading to his left leg was compressed and triggered the shooting pain down his leg. If the symptoms do not change with physiotherapy, Mr Lim may require an operation to his spine. (The majority of people with back pain improve with physiotherapy, however, severe cases resort to surgery.)
Case Study 2 - Legal Secretary
Ms Tan has been a legal secretary for a law firm for close to ten years. In the last few years, she spent a lot more time in front of the computer and gotten faster at her typing. In the last six months, she had to spend between eight to ten hours non-stop at the keyboard. Recently, she had to quit her job because of the pain, tingling and weakness in her forearms, wrists and fingers from the excessive typing. She is now undergoing intensive physiotherapy to relieve the symptoms and regain the strength in her fingers that she has lost.
Early symptoms
Two years ago, Ms Tan occasionally had a 'funny' feeling in her hands while typing, but as soon as she rested, the 'funny' feeling subsided. It was not there all the time, only after really intense typing when she had to meet deadlines. As the workload increased, the feeling happened more often, but she did not take much notice.
Management & outcome
At this stage, Miss Tan would have had to slow down her pace, take regular mini breaks and alternate typing with non-typing work during the day. She could have been more aware of the importance of good ergonomics at her workplace and made some adjustments to her chair height, the position and height of her monitor, keyboard and mouse. She would have benefited from knowing the right typing techniques. Instead of typing with her wrists bent upwards and resting them on the table, she should have been typing with straight wrists (without hingeing them up, down, left or right) with the elbows relaxed by her side at a 90-degree angle. These measures would have prevented any worsening of her symptoms.
Mild symptoms
She began to experience intermittent twinges of pain in her wrists and tingling in her fingers while typing. Her colleagues noticed that occasionally she would stop typing to massage her wrist, but stoically would continue at top speed to live up to her reputation as 'one of the most efficient employees in the company'.
Management & outcome
Besides ergonomics, good typing techniques, task variation and pacing herself, Ms Tan might have needed some therapy at this stage to massage her overused muscles and show her how to stretch and strengthen muscles of the shoulders, forearms, wrists and hands. She would also have benefited from learning good posture and the importance of using the larger, stronger muscles of the shoulder to move the arm over the keyboard rather than stressing the smaller, weaker muscles of the wrist and fingers to stretch and reach the keys. Finding time to keep fit would have helped her to better cope, physically and mentally, with her job.
If she had taken these simple steps, complete recovery would have been possible in a short period of time and she would have had the knowledge to prevent the worsening of her symptoms.
Moderate symptoms
Colleagues noticed that she dropped things more regularly than before and had a tendency to shake out her hands in between typing and rub her forearms more vigorously. The pain in her wrists was more severe and the tingling more annoying. The symptoms were more frequent and were not always relieved by rest. She was advised to seek treatment but the company was short on staff and there was no time.
Management & outcome
At this stage, Ms Tan had a moderate risk of permanent impairment if she did not change her work habits, seek treatment and get to the root of the problem. The repetitive motion of the fingers from typing thousands of words a day at high speed with minimal breaks day after day, had caused widespread micro-tears to the tendons and muscles of her fingers, wrists and forearms. If she continued at the same intensity, the tears would not have time to heal and the bonds between them would get weaker, developing a tight, haphazard mesh of scar tissue. The tingling in the fingers was caused by nerves and arteries being compressed by swelling and scar tissue.
Chronic pain
Ms Tan was starting to have great difficulty doing any sort of typing, dialing numbers on the phone or writing or picking anything up due to the weakness and constant pain in her wrist and fingers. She was very depressed and had to take sick leave because she was unable to work as most of her work involved the computer. The thought of typing brought on the pain. At home, she could not pick up her baby because the pain was so severe and she had to take heavy doses of painkillers. She was unable to drive because gripping the steering wheel would bring on a sharp, shooting pain.
Management & outcome
At this point, she is at high risk of permanent impairment and therapy is likely to be a long process before there is any improvement. She would have to give up her job and rest her hands from any aggravating activities for a long time in order to avoid permanent disability. This is likely to take years given the time it took to reach this level of severity. It is most likely that even after years of rest and rehabilitation, she would be unable to use her hands for keyboarding activities. Once she touches a keyboard with any sign of recovery, the chances of relapse are high and the re-injury could be worse than previously experienced. Surgery may be a consideration. However, there is no guarantee of success and in some cases, can actually trigger a serious condition known as Reflex Sympathetic Dystrophy in which the condition of the hand deteriorates to the extent that it changes appearance and the pain is constant with an intense, burning quality.
If you are noticing symptoms in your neck, shoulders, elbows, forearms, wrists or fingers which are aggravated by work, it is important to seek treatment before it develops into a serious condition which may affect your ability to work or function normally.
Trina Lee
Physiotherapist
Physiotherapy Centre
Trina Lee is a physiotherapist specialising in ergonomics and work-related injuries. She treats patients with CTI on a regular basis and conducts talks and workplace evaluations with the aim of preventing such injuries. She has set up her own private practice at the Physiotherapy Centre, 400 Orchard Road, #07-03, Orchard Towers, Singapore 238875, and may be reached via telephone on 737 0341, 235 0561 & 9760 2175 or e-mail at trinapt@pacific.net.sg.