An inside look: Hand injury-prevention program

The purpose of this article is to review the development of an industrial hand injury-prevention program to provide the impetus for other hand therapists to undertake such programs. The article includes a description of how to initiate a prevention program, the content of the training seminar, presentation methods, and marketing strategies. The "Handle with Care" program was effective in reducing the cost and incidence of industrial hand injuries and was favorably received by Oklahoma industry at its inception. A new program is currently being developed in California. (J HAND SURG 19S7;12A[2 Pt 2]:940-3.)

Barbara Lee Smith, B.S., O.T.R., San Francisco, Calif.

T here is a growing resource of informa­tion concerning prevention of hand injuries in the work place, including ergonomic job design, employee risk factors, and alarming injury statistics. Little has been done to fill the void of information necessary for an injury-prevention program. The hand therapist has the professional background and clinical experience to offer education in this area from a unique perspective. Ef­fectiveness of preventive medicine is enhanced when associated with clinical programs that are philosoph­ically coordinated with the preventive programs. l

Development of the program

In 1983 an hour-long pilot program was presented to the supervisors of a company in Oklahoma. From that point on, "Handle with Care"2 grew into an 8-hour training seminar to enable participants to present, rec­ognize, and correct hand hazards in their place of busi­ness. Four years of refining and developing each area of that initial program has resulted in the format that we discuss here.

Establishing a need

The first step in the development of any new service is the establishment of the need for that particular ser­vice. If your primary consumer is industry, why not ask industry? This can be initiated through clinic rec­ords of patients injured at work. As a rule, progress reports on all of the workers' compensation patients were sent to their employers at 2-week intervals to

From the Davies Medical Center, Hand Therapy Center, San Fran­cisco, Calif.

Reprint requests: Barbara Le~ Smith, B.S., Davies Medical Center, Hand Therapy Center, Castro and Duboce, Suite WI. San Fran­cisco, CA 94114.

940 THE JOURNAL OF HAND SURGERY

inform them with respect to therapy attendance, treat­ment, and home instructions. In this way, there is an open door of communication that can be used as a starting point for injury prevention. Initially, visiting and talking with the personnel manager, industrial health nurse, or whoever has been designated as the safety representative is a good beginning. The question then becomes: What do they see as a way to reduce injuries? If an educational program were offered, what topics would they like covered? Discussions with com­pany personnel help the therapist identify the wants and needs of the consumer.

The next logical step is to discuss the problem, using the available statistics. For example, absenteeism and its effects on cost,3 where the employer's average health care dollar is spent,4 the number of lost-time accidents involving the upper extremity,5 and the behavior-related causes of injury6 might be discussed. It is noted that 60% of those injured had not received safety training. 7

The facts are readily available and serve to reinforce the data collected by the individual company.

Once the needs of industry have been voiced and the figures tabulated, the experienced hand therapist can draw on these resources to offer a comprehensive in­dustrial hand injury-prevention program. A free I-hour program allows the company decision makers to ex­perience directly a sample of the program format, qual­ity of presentation, and content. This makes the mar­keting of a fairly intangible educational service more tangible. Brochures that describe the newly developed service are mailed to company safety representatives to assess their willingness to have a brief presentation made on site. A postcard indicating interest is returned; if not, a follow-up telephone call is made.

The objectives for the hand injury-prevention pro­gram were developed from previous discussions and

Vol. 12A, No.5, Part 2 September 1987

improved after critiques of the actual presentation. The primary objectives are (1) to increase awareness of the frequency and cost of injuries to the upper extremity, (2) to illustrate why a hand injury can be so devastating to the worker, (3) to examine the common causes of and actual injuries to the upper extremity, and (4) to discuss what can be done to reduce injuries in the work­place. Second, the objectives of this course are (1) to reduce the number and cost of hand injuries, (2) to reduce the number of worker days lost to serious in­juries, and (3) to advocate the services of the center presenting the program.

The presentation of the entire 8-hour seminar makes use of a variety of media. Each participant receives a booklet, slide carousel, and script. Throughout most of the day, the primary form of education comes in the way of lecture and slide presentations. Demonstrations and models can be used in anatomy and first aid care. It is also helpful to set out a display of "rehabilitation items," such as putty, splints, and evaluation tools. If available, display of a variety of gloves and hand tool designs can be useful in demonstrating causes and pre­vention of injuries. In addition to lecture, written ma­terial, slides, and other tangible media, the use of video tape recordings provides another dimension.

Content of training seminar

The introduction emphasizes the need for injury preven­tion. This is the time the presenter can use all of the statistics available on the direct and indirect costs to industry and the frequency with which injuries to the upper extremity occur. Although the larger numbers are impressive, the smaller, scaled-down percentages and dollar figures are more tangi­ble. 7 Statistics can be gathered from clinic or hospital records, if accessible, to make the numbers more realistic.

Daily hand activities. "A Day in the Life of a Hand" slide segment came about in response to patients' comments after an injury occurs. It reflects the day-to-day activities that are taken for granted until they can no longer be performed. The emotional impact begins in this section and is reinforced at various intervals. The participants observe hands performing functional activities and conveying emotion as an appeal to our basic needs.

Anatomy. Skilled hand function is a resultant of intricate anatomy. The anatomy review is on the basic knowledge and comprehension level of learning. It includes a definition and illustration of structures, such as muscles and tendons, surface anatomy, and the circulatory, nervous, and skeletal systems. Emphasis is placed on the participant's being able to recall one basic function of each structure and, later, being able to recognize those structures as they relate to hand injuries.

Physiology of injury. The following segment of the pro­gram is the physiology of injury, which again helps to build basic knowledge. Now that the subjects know what a tendon

Hand injury-prevention program 941

is, it is much easier to explain what happens to it during cumulative trauma. Hence, edema and inflammation are ad­dressed, as well as the healing process of nerves and fractures. In addition, slides of actual injuries help to illustrate these points.

First aid care. Emergency first aid care is usually pre­sented by nursing personnel. Such topics as the care of an amputated part are followed by bum care and first aid to treat lacerations and abrasions. The participants need to become acquainted with the new methods and materials available for providing proper first aid. A practice session familiarizes each person with the necessary components of a first aid kit.

Causes of injury. In the next segment, which is perhaps the most important, causes of injury and risk factors are ex­amined. The first look is at the task performed by the worker. Also, what was the environment at the time of the accident? Proliferation of the work-related injury "epidemic" requires the interaction of a causative agent within a particular envi­ronment and a sensitive host. 5 The causative agent may be associated with poor tool design, improper work heights, or repetitive tasks. Actual on-site slides accurately depict each situation so that the safety manager can begin to assimilate the knowledge acquired earlier in the seminar.

The host, or worker, represents the human factor. and human behavior is the most difficult to control. 9 There are characteristics common to most people that help cause ac­cidents because people tend to (1) make mistakes, (2) forget, (3) get in a hurry, (4) become preoccupied, (5) don't always do as they are told, (6) not always know what they should do, (7) not always recognize a potential hazard. 9 There is a tendency to minimize a hazard even when recognized by a worker. 7 Human factors rank high in the cause of injuries. 10

Common industrial injuries. Common hand injuries range from cumulative trauma disorders to crushing injuries. This section can be tailored to meet the needs of the particular audience if they are known ahead of time. Slides depicting injuries acquired in the manufacturing business would be most applicable to the majority of persons. National statistics in­dicate that 60% of the injured workers are employed in man­ufacturing. 7 Again, participants are required to recall past knowledge to relate anatomy and physiology to the actual injury scenarios presented.

Rehabilitation after injury. One of the most interesting facets of the prevention program is tying it all together with rehabilitation after injury. The therapist can explain why it can take so long from surgery to return-to-work status. It helps to dispel the mystery for the employers. Although re­habilitation is not directly related to the prevention of indus­trial injuries, it should be emphasized that quality hand ther­apy can reduce the length and severity of the disability.'

Prevention. Prevention, the primary objective, can be broken down into two basic approaches. Active prevention requires action on the part of the worker; i.e., each employee must put on protective gloves. Passive protection, on the other hand, works to protect the employees despite themselves. An example would be use of a machine guard. Passive ap­proaches, although most reliable, are not a panacea. Unpre-

942 Smith

dictable human behavior affects active approaches, which require 100% cooperation on the part of the worker to be effective. Since human subjects find a way to get under or through or to remove machine guards, it would seem that both approaches are necessary to achieve results. The em­ployee education program encourages the workers to take an active role in the prevention of injuries."

Review of employee program. Near the end of the training seminar, the actual I-hour employee program is reviewed to allow for questions. Suggestions for customizing the program are discussed; for example, slides taken at the work place might be substituted for slides included in the carousel to make the presentation more pertinent to the employees in a specific program. The employee program is an abbreviated summary of the trainer's course. Objectives identified for the worker include (I) recalling how lifestyle can be affected by a hand injury, (2) naming of two causes of hand injuries at work, (3) demonstrating hand exercises, and (4) relating hand hazards to workplace and home situations.

Video interviews. The final presentation is the video tape recording of patient interviews. The primary goals are to make it clear to the employee that anyone can have a hand injury. Second, it makes the possibility of injury more real; again, there is an emotional appeal to think safety first. Each patient is asked a series of questions relating to the circumstances surrounding his or her injury. When patients were asked what advice they would offer to others to help prevent an accident, they were most convincing in relating their "hindsight" ex­perience.

Conclusion. In concluding the program, the safety rep­resentatives are asked to apply their newly acquired knowl­edge to actual situations. Discussions of actual hazards en­countered in the work place facilitate problem solving. Also used are slides taken at various industries, with the question: "What is wrong with this picture?"

Marketing

Follow-up after the presentation is made is good mar­keting. This is the opportunity to improve on any prob­lem areas and reinforce the hand center's name and services as a resource. It may serve as an opportunity to offer new services, such as a refresher course after 6 months. Course evaluations offer an excellent source of ideas for new programs and, in addition, reinforces the fact that there will be a follow-up to the course. Thus, the consumer receives a clear message of com­plete service.

The greatest benefit to the employee is the fact that this educational program increases the level of injury awareness. In this way workers become active partici­pants in the prevention of their own injuries. Knowledge of basic anatomy and causative agents help to substan­tiate the premise of prevention.

Benefits to the company, when education is used as a part of prevention, include not only a reduction in the

The Journal of HAND SURGERY

number of injuries but also a cost savings. One Okla­homa company instituted a I-year comprehensive plan to promote health and safety in the workplace. The results in 1986 were a 72% reduction in lost-time ac­cidents, with a 64% savings in workers' compensation reserve costs. 12 The knowledge gained by attending the seminar enables the safety representative to better un­derstand injury claims and to spot and recommend cor­rection of potential hand hazards.

One seIling point of this injury-prevention program is that it may help industries to meet national safety and health requirements. It can also be easily custom­ized, to meet the needs of individual companies by substituting slides with those that depict problems per­tinent to the setting. Previous course evaluations re­garding program content and method of presentation reflect 67.6% excellent ratings, 27.6% good, and only 4.8% average. A major oil company presented the pro­gram to upper-level management, who recommended that all employees participate; in addition, an out-of­state associate came in to preview the class. Conver­sations with past participants yielded similar comments, such as one chemical company that recorded 18 severe injuries before the 1984 program but reduced the figure to three injuries the following year.

Summary

Hand therapists can have a positive impact on re­duction of the incidence of hand injuries through a prevention program. In addition, they receive the ben­efits of added exposure to industry. Thirty-two com­panies were represented at the "Handle with Care" train­ing seminars over a 3-year period. The manufacturing industry accounted for 37.5% of the participants, oil and gas companies another 37.5%, health care 6.3%, 3.1 % insurance, and the remaining 15.6% were in other types of business. Course evaluations reflect the fact that the information presented was useful and well pre­sented and that the time spent on each topic was ade­quate. The 8-hour contact enables the safety represen­tative to fully understand the background information essential to effective injury prevention. A pretest ad­ministered to participants indicated that 79% of the questions were answered incorrectly. After the seminar, the posttest reflected only 21 % incorrect answers. The safety representatives indicated that the program met their objectives and they would later feel comfortable in fielding employee questions. "Handle with Care" enabled us, as therapists, to better rehabilitate the in­dustrially injured employee by facilitating a better understanding of the needs of the employer and the employed.

Vol. 12A, No.5, Part 2 September 1987

REFERENCES I. Johnston B, Blakney M. Industrial health program: Al­

ternative or obligation? Clin Management 1986;2: 18-22. 2. Allen BA, McConnell D, Goodell B, Crow J. Handle

with care-Hand safety manual. Presbyterian Hospital, 1984:1-46.

3. Strasser AL. Medical absenteeism and the auto industry. Occup Health Saf 1982; 17 -18 .

4. The corporate Rx for medical costs . Business Week 1984 Oct 15:138-48.

5. Polakoff PL. Traumatic job injury rate needs to be ex­amined, decreased. Occup Health Saf 1985;55:83-4.

6. Behan RC, Hirschfeld AH . The accident process. JAMA 1963;186:84-90.

Hand injury-prevention program

7. What causes hand and arm injuries? National Safety News 1983 July:42-5.

8. Levitt T. Marketing intangible products and product in­tangibles. Harvard Business Review 1981;59:94-102.

9. Blair SJ, Allard KM . Prevention of trauma: A cooperati ve effort. J HAND SURG 1983;8:649-53 .

10. Absoud EM, Harrop SN. Hand injuries at work . J HAND SURG 1984;9B:211-15 .

II . Haddon W Jr. Strategy in preventive medicine: Passive vs. active approaches to reducing human wastage. J Trauma 1974;14:353-4.

12. Hughes Tool Company. Centrilift safety program cuts job injuries. Hughes Review, Claremore, Oklahoma, 1987.

Thermography in the detection of carpal tunnel syndrome and other compressive neuropathies

Studies were conducted using liquid crystal thermography (FlexiTherm) and electronic ther­mography for the diagnosis of carpal tunnel syndrome. Studies were also conducted to differ­entiate carpal tunnel syndrome from peripheral neurovascular injuries. Ninety patients were included in the study, with an average follow-up time of 24 months. Fifty patients also had electric studies for comparison and contrast. Thermal patterns of carpal tunnel syndrome showed a decreased vascular heat emission pattern over the median nerve distribution. The procedures using thermography consisted of imaging of the cervical spine, shoulders, forearms, and hands by Wexlerian guidelines to obtain diagnostic thermograms and a stress series. Results of the studies showed that thermographic studies were efficacious and sensitive for the differential diagnosis of carpal tunnel syndrome from other peripheral compressive neuropathies, including cervical radiculitis, thoracic outlet syndrome, cubital tunnel syndrome, and Guyon's canal syn­drome. Biomechanic and etiologic factors indict carpal tunnel syndrome to be an occupational disease. Thermographic technique use may lead to the early diagnosis, treatment, and preven­tative measures that could eliminate the high cost of manpower loss and of medical care often concomitant with carpal tunnel syndrome. (J HAND SURG 1987;12A[2 Pt 21:943-9.)

Richard T. Herrick, M.D., F.A.C.S., and Stella K. Herrick, A.M.W.A., Opelika, Ala.

Carpal tunnel syndrome, compression of the median nerve at the wrist, is the most common of the entrapment neuropathies that afflict the upper ex­tremity. I Although it was described in the 19th century the condition is still often overlooked, in spite of a

From the School of Industrial Engineering, Auburn University. Au­burn and Opelika, Ala.

Reprint requests: P.O. Box 4160, Opelika, AL 36803.

considerable increased prevalence now, which appears to parallel the rise of industrialization. 24

The increasing incidence of carpal tunnel syndrome is considered to be primarily due to the increased abnormal use of the hand in vocational and avoca­tional settings that require repetitive wrist and finger motion. 5

.6

In the workplace, the syndrome affects workers whose occupation involves deviation of the wrist from

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