HEALTHY WOMAN
News from the Office of Women’s HealtH
Summer 2001

UNINTENTIONAL INJURY EDITION

Are women more susceptible to some injuries than men?

Yes, because of a woman's biological and physiological make up women are more prone to some types of injuries than men. For example, the rate of hip fracture is two to three times higher in women than men, women experience nearly two-thirds of all work related carpal tunnel syndrome and repetitive stress injuries, and women are four to six times more likely to suffer serious knee injuries than men. Following are articles describing these issues and ways to prevent each from occurring.

AT WORK

Carpal tunnel syndrome: What is it and how can it affect you?

The carpal tunnel is the tunnel-like structure formed by the carpal bones and tendons in the wrist that provides the pathway for the median nerve to send nerve impulses to the fingers and base of the thumb. When the tendons become inflamed, they put pressure on the median nerve and carpal tunnel syndrome (CTS) results.

Carpal tunnel syndrome is more common in women, especially after age 30, and is most often caused by repetitive and forceful movements of the wrist during work and leisure activities. According to the U.S. Bureau of Labor Statistics, "disorders associated with repeated trauma" account for 60 percent of all occupational illnesses and, of these disorders, carpal tunnel syndrome is the most frequently reported. With an average case of carpal tunnel syndrome, 30 days of work are lost, accounting for the highest number of work days lost, of all major work- related injuries.

Symptoms of carpal tunnel syndrome

• Numbness or tingling in your hand and fingers, especially the thumb, index and middle fingers
• Pain in your wrist, palm or forearm
• More numbness or pain at night than during the day. The pain may be so bad that it wakes you up.
• More pain when you use your hand or wrist more.
• Trouble gripping objects.
• Weakness in your thumb.

Who is most at risk for carpal tunnel syndrome?

Since carpal tunnel syndrome is associated with repetitive motions of the hand and wrist, it is most commonly found in those with jobs requiring repetitive motions such as computer operators, carpenters, grocery checkers, assembly-line workers, meat packers, violinists and mechanics. Hobbies such as gardening, needlework, golfing or canoeing can also bring on the symptoms of carpal tunnel syndrome.

Diagnosis

In most cases, an accurate medical history and clinical examination will establish the diagnosis.  During a clinical exam, your doctor may test for symptoms using Phalen's test (bending the wrist firmly palmward for 60 seconds to duplicate symptoms) or by tapping the front of the wrist over the nerve (Tinel's sign). For questionable diagnoses, a nerve conduction or electromyography test (EMG) may be conducted, though these are more uncomfortable and expensive.

Treatment

Non-operative treatment may be attempted for patients with recent, mild or intermittent symptoms. It includes the use of anti-inflammatory drugs and night splints to prevent wrist flexion. However, most cases will recur if the underlying cause of the nerve compression continues. Unless significant improvement is noted early in such treatment, surgical treatment may be necessary.

In most cases of carpal tunnel syndrome, either traditional open surgery or endoscopic surgery, where a telescope is used to visualize the nerve and transverse ligament, will provide permanent relief for 80 percent to 90 percent of patients.

Surgery is performed by cutting the transverse carpal ligament that forms the roof of the carpal tunnel to relieve pressure on the median nerve. The surgery is performed at an outpatient facility and full recovery usually occurs over several weeks to a few months.

In some cases, where the nerve has been permanently damaged, surgery will not completely relieve the pain associated with carpal tunnel syndrome. Therefore, it is important to take the measures necessary to prevent the onset or worsening of carpal tunnel syndrome.

Prevention

Carpal tunnel syndrome occurs most often in workers whose motions are not only repetitious, but are continued for hours at a time. Here are some suggestions that may help prevent carpal tunnel syndrome:

• Lose weight if you are overweight.
• Get treatment for any underlying disease that may be causing carpal tunnel syndrome.
• If you do the same tasks with your hands over and over, try not to bend, extend or twist your hands for long periods of time.
• Don't work with your arms too close or too far from your body.
• Don't rest your wrists on hard surfaces for long periods of time.
• Switch hands during work tasks.
• Make sure the tools you use are not too big for your hands.
• Take regular breaks from repeated hand movements to give your hands and wrists a rest every 10-15 minutes each hour.
• Don't sit or stand in the same position all day.
• If you use a keyboard, adjust the height of your chair so that your forearms are level with the keyboard and you don't have to flex your wrists to type. (there should be a 90 degree angle between your upper arm and forearm, as well as your thigh and torso)

Exercises like the following can also help:

A. Make tight fists, holding for one second, then release and stretch your fingers wide. Hold for five seconds. Repeat several times.

B. Stretch your arms out in front of you. Raise and lower them in outstretched position several times. Next, rotate your hands 10 times by making circles in the air with your fingertips.

Contact the following for more information on carpal tunnel syndrome:

American Chronic Pain Association (ACPA)
ACPA@pacbell.net
www.theacpa.org
Telephone: 916-632-0922

Association for Repetitive Motion Syndromes (ARMS)
arms@lightspeed.net 
www.certifiedpst.com/arms/
Telephone: 303-369-0803

National Chronic Pain Outreach Association (NCPOA)
ncpoa@cfw.com
Telephone: 540-862-9437

NIAMS/National Institute of Arthritis and Musculoskeletal and Skin Diseases
namsic@mail.nih.gov
www.nih.gov/niams/
Telephone: 877-226-4267 301-496-8188

References
1 NIOSH Facts: Carpal Tunnel Syndrome, National Institute for Occupational Safety and Health, June 1997.

23 Facts about Carpal Tunnel Syndrome, American Academy of Orthopaedic Surgeons, April, 1997.

3 Carpal Tunnel Syndrome: Preventing the Pain in your Hands and Wrists, American Academy of Family Physicians Family Health Facts Series.

4 ibid.

5 Carpal Tunnel Syndrome, Center for Orthopaedics & Sports Medicine, 1999.

6 ibid.

7 Carpal Tunnel Syndrome, American Academy of Orthopaedic Surgeons, 2000.

7 Sheehan, Mark, Avoiding carpal tunnel syndrome: A guide for computer keyboard users, University Computing Times, July-August 1990, pp. 17-19.

9 NINDA Carpal Tunnel Syndrome Information Page, National Institute of Neurological Disorders and Stroke and National Institutes of Health, Bethesda, MD, 2000.

Did You Know...

In Illinois, there are approximately 6,000 deaths from unintentional injuries annually; they are the leading cause of death for ages 1-34. Unintentional injuries are those that are accidental and include such things as motor vehicle crashes, poisoning, falls, suffocation and burns. In addition, unintentional injuries often cause disabilities that greatly decrease a person's quality of life and productivity.

Motor vehicle injury accounts for the greatest number of fatalities among all unintentional injury causes. Though the rate of motor vehicle deaths in  women (10.1 per 100,000) is less than half that of men (21.9 per 100,000) nationally, it still accounts for the greatest number of unintentional injury deaths in women. Top causes of unintentional injury deaths in U.S. women are shown in the chart to the right.

(Adapted from: State Injury Profile 2000 Appendix in U.S. Centers for Disease Control and Prevention (CDC) Injury Fact Book, Working to Prevent and Control Injury in the United States and U.S. Department of Health and Human Services. Health, United States, 2000 with Adolescent Health Chartbook and Health United States 1996-1997 and Injury Chartbook.)

AT PLAY

Women Have More Sport and Exercise Related Injuries than Men

The benefits of exercise are many, from decreasing the risk of heart disease and stroke to reducing stress and helping us feel energized. However, though seldom mentioned, exercise-related injuries can occur if the proper precautions are not taken, especially for women.

Studies show that injuries are common among those who exercise or are involved in sports and women have even higher rates of sport and exercise-related injury than men. For instance, injuries among women going through basic military training are approximately twice those experienced by men; women's risk for serious injury is 2.5 times greater than for men.1 Though studies of the effects of exercise in the military are not exactly the same as studying the effects of injury in the civilian population, they often shed light on issues that do occur in the civilian population.

Since Title IX went into effect in 1972 preventing sex discrimination in educational settings, the number of high school girls in sports has grown from approximately 300,000 in the early 1970s to 2.7 million (an 800 percent increase). That amounts to about one in three high school girls playing sports.2 The number at the college level is also increasing. Likewise, many women begin exercise programs for health reasons and to improve their appearance, though they may not be involved in competitive sports.

What do the studies reveal and what are the risk factors for exercise-related injury?

Recent studies now indicate that a person's current level of physical fitness is one of the most important predictors of exercise-related injury. During military basic training, low levels of aerobic fitness and low muscular endurance have been consistently associated with injury risk.  Although women going through basic training experienced twice as many injuries as men, when aerobic fitness level is controlled for in studies, this difference diminishes to almost zero.

Therefore, the difference in injury rates between the sexes may be more a result of lack of physical fitness than actual gender differences.3 Although such studies have not been conducted in the civilian population, these findings imply that lack of aerobic fitness may also be a leading risk factor for exercise-related injuries among civilians.

Recommendations for Prevention4

Based on the above findings, recommendations for prevention of exercise-related injuries include the following:

• Be realistic when setting exercise goals.
• Tailor exercise to accommodate your current level of fitness and increase frequency, duration and intensity gradually.
• Use a 10 percent rule. Increase training by 10 percent increments. Women who have been sedentary and are just beginning an exercise program should start with five to ten minutes of light-intensity exercise and gradually increase to the desired level of intensity or duration.
• If you are over age 50 or if you have a chronic disease or risk of a chronic disease, consult your physician to ensure that your exercise program is safe.
• Encourage your daughters to play sports and to start exercising regularly at a young age to gain a high level of fitness to protect them against future injury. If a girl does not get involved in sports by the time she is 10, there is less than a 10 percent chance that she will be involved in sports when she is 25.
• Be aware of early signs of potential injury. Increasing muscle soreness, bone and joint pain, excessive fatigue and performance decreases are signals that the body needs to rest. Trainers and coaches should also be aware of these signs. When any of the signs are present, incrementally decrease the frequency, duration or intensity until the signs are no longer present. In some cases, it may be necessary to stop the activity for a time so that the injury can heal fully.
• If possible, ask a trainer or coach to assess the level of intensity at which you should exercise  to gain the most from the exercise without injury. Once you know the heart rate at which you should exercise, check it frequently to see if you are exercising at the proper level. A good rule of thumb is that you should be able to talk while you exercise. If this is not possible, you are probably exercising too hard.
• If injured, allow sufficient recovery and rehabilitation time to prevent reinjury.

Remember, exercise keeps you healthy in so many ways, preventing cardiovascular disease, stroke, diabetes and cancer, as well as being great for your mental and emotional well-being. You need to keep yourself injury free so that you can continue exercising to reap all these benefits. One of the surest ways to prevent injury while exercising is by keeping a high level of fitness. In addition to following the prevention guidelines above, this will involve encouraging your daughters to begin exercising as early as possible and to continue to exercise regularly throughout life.

References

11 Bell, N., Lack of Physical Fitness Causes Higher Sports Injury Rates Among Women, Center for the Advancement of Health, March 16, 2000.

2 Gilchrist, J., Jones, B.H., Sleet, D.A. and Kimsey, C.D., Exercise-Related Injuries Among Women: Strategies for Prevention from Civilian and Military Studies, National Center for Injury Prevention and Control and U.S. Centers for Disease Control, March 31, 2000/49(RR02);13-33.

3 Ibid.

4 Recommendations for Prevention are adapted from 1) Gilchrist et. al., 2) Prevention of Training Injuries, Association of Women's Fitness and Health and 3) Lopiano, D.A., Recounting our Thoughts about Girls and Sports, Women's Sports Foundation.

AS WE AGE

Osteoporosis Causes Fractures in One out of Every Two Women

(Compiled and adapted from articles of the National Osteoporosis Foundation, 2001; National Institutes of Health, U.S. Preventive Services Task Force, 1996; and Illinois Department of Public Health, 1992-1995 data)

One of every two women will suffer from osteoporosis in her lifetime. Osteoporosis leads to bone fragility and an increased risk of fracture of the hip, spine and wrist. Hip fracture is the most serious consequence of osteoporosis, affecting 15 percent of women. These fractures are an important health care concern for several reasons:

• 300,000 Americans age 45 and over are admitted to hospitals with hip fractures each year and hip fractures are the second leading cause of nursing home admissions. Osteoporosis was the underlying cause of most of these hip fractures. Hospitalization rates for hip fractures in Illinois are 10 percent to 20 percent higher than the national average. By 1995, hospitalization costs for osteoporosis in Illinois had reached $243 million, an increase of 13 percent since 1992.
• 24 percent of hip fracture patients age 50 and over die in the year following their fracture.
• Only one-third fully regain their pre-fracture level of independence.
• Even after one year, more than 40 percent of patients still cannot walk unaided.
  

Women and Hip Fracture

The rate of hip fracture is two to three times higher in women than in men. Approximately 90 percent of hip fractures can be attributed to osteoporosis in white women age 65 and older. For women age 85 and older, 95 percent of hip fractures can be attributed to osteoporosis.1 Other populations also are at significant risk, but the attributions are slightly lower than for whites.

A woman's risk of hip fracture is equal to her combined risk of breast, uterine and ovarian cancer.

Diagnosis

Osteoporosis is diagnosed through a bone mineral density test (BMD), which determines risk for future fracture. A BMD measures the density of your bones (bone mass) and is necessary to help determine whether medication is needed to help maintain bone mass, prevent further bone loss and reduce fracture risk. The BMD test is accurate, painless and noninvasive. Since osteoporosis can develop undetected for decades until a fracture occurs, early diagnosis is important for anyone with any of the following risk factors.

What puts a woman at risk for osteoporotic fracture?

• Personal history of adult fracture or history of fracture in a first-degree relative
• Caucasian or Asian race*
• Advanced age
• Dementia
• Current cigarette smoking
• Low body weight (< 127 lbs)
• Estrogen deficiency:
  • --Early menopause (< age 45)
  • --More than one year without menstruation (during childbearing years)
• Low calcium intake (lifelong)
• Alcoholism
• Impaired eyesight despite adequate correction
• Recurrent falls
• Inadequate physical activity
• Poor health/frailty

* Note: While Caucasians and Asians appear to be at highest risk, risks for those of other races or ethnicities can still be substantial.

Calcium

Calcium is needed for the heart, muscles and nerves to function properly and for blood to clot. Inadequate calcium is thought to contribute to the development of osteoporosis. National nutrition surveys have shown that many women and young girls consume less than half the amount of calcium recommended to grow and maintain healthy bones.

Foods Rich in Calcium

• Skim milk, 1 cup (300mg)
• Lowfat milk, 1 cup (295 mg)
• Whole milk, 1 cup (290 mg)
• Yogurt (plain, lowfat), 1 cup (415 mg)
• Frozen yogurt (fruit), 1 cup (240 mg)
• Part-skim ricotta cheese, 4 oz. (335 mg)
• Swiss cheese, 1 oz. (270 mg)
• Cheddar, mozzarella or muenster cheese,  1 oz. (205 mg)
• Soft-serve vanilla ice cream, 1 cup (236 mg)
• Vanilla ice cream, 1 cup (176 mg)
• Calcium-fortified orange juice, 1 cup (300 mg)
• Sardines with bones (canned), 3 oz. (372 mg)
• Salmon, canned, with bones, 3 oz. (167 mg)
• Collard greens (cooked), 1 cup (357 mg)
• Turnip greens (cooked), 1 cup (252 mg)
• Soybeans, cooked, 1 cup (131 mg)
• Tofu, 4 oz. (108 mg)*

* Calcium content of tofu varies depending on processing method; check nutrition label.

Recommended Calcium

Intakes

The Food and Nutrition Board of the National Academy of Sciences recommends the following daily intakes of calcium:

· 210 mg for infants birth to 6 months
· 270 mg for infants 6 months to 1 year
· 500 mg for children 1 to 3 years
· 800 mg for children 4 to 8 years
· 1300 mg for children 9 to 18 years
· 1000 mg for adults 19 to 50 years
· 1200 mg for adults 50+ years

Source for Recommended Calcium Intakes: Perspectives in Nutrition, by Gordon M. Wardlaw (WCB McGraw-Hill,1999)
Source for Foods Rich in Calcium: Adapted from National Osteoporosis Foundation, 1991

If you have difficulty getting enough calcium from the foods you eat, you may take a calcium supplement to make up the difference.

Vitamin D

Vitamin D is needed for the body to absorb calcium. Without enough vitamin D, you will be unable to absorb calcium from the foods you eat, and your body will have to take calcium from your bones. Vitamin D comes from two sources: through the skin following direct exposure to sunlight and from the diet. Experts recommend a daily intake between 400 and 800 IU per day, which also can be obtained from fortified dairy products, egg yolks, saltwater fish and liver.

Exercise

Exercise is also important to maintaining bone health. If you exercise regularly in childhood and adolescence, you are more likely to reach a greater peak bone density than those who are inactive. The best exercise for your bones is weight-bearing exercise such as walking, dancing, jogging, stair- climbing, racquet sports and hiking. If you have been sedentary most of your adult life, be sure to check with your health care provider before beginning any exercise program.

Medications for Prevention and Treatment

Although there is no cure for osteoporosis, five medications are approved by the U.S. Food and Drug Administration (FDA) for prevention and/or treatment of osteoporosis. Each of these medications slows or stops bone loss, increases bone density and reduces fracture risk.

Drugs to Prevent Osteoporosis Drugs to Treat Osteoporosis

• Estrogen/hormone replacement therapy ERT/HRT ERT/HRT
• Alendronate Calcitonin
• Raloxifene Raloxifene
• Risidronate Alendronate (when glucocorticoid-induced)
• Risidronate (when glucocorticoid-induced)

These medications affect the bone remodeling cycle and are classified as anti-resorptive medications. Bone remodeling consists of two distinct stages: bone resorption and bone formation. During resorption, special cells on the bone's surface dissolve bone tissue and create small cavities. During formation, other cells fill the cavities with new bone tissue. Usually, bone resorption and bone formation are linked so that they occur in close sequence and remain balanced. When osteoporosis is present, the balance is altered and bone loss occurs. Anti-resorptive medications slow or stop the bone resorbing portion of the bone-remodeling cycle but do not slow the bone-forming portion of the cycle. As a result, decreases in bone density are slowed and in some cases bone density may even increase.

Importance of Rehabilitation and Fall Prevention

It is very important that people recovering from a fracture receive rehabilitation to improve muscle strength and coordination to help prevent future falls and fractures. Fractures of the hip often change a person's gait, and vertebral fractures can cause postural changes. Unfortunately, these consequences of fracture can further increase the risk of falls and more fractures, so rehabilitation is vital, as well as instruction in safe movement. See your doctor for more information on ways to prevent falls. In addition, the home should be fall-proofed and common household hazards such as slippery floors, scatter rugs and unlit stairways should be addressed. The National Osteoporosis Foundation is drafting a rehabilitation guide for physicians and publishes a booklet on fall prevention, Falls and Related Fractures, with tips on fall-proofing the home. For more information about osteoporosis and hip fracture, visit http://www.nof.org/osteoporosis/ .

The Falls and Related Fractures brochure, as well as many other educational materials, can be ordered on-line.

Office of Women's Health Grant Program Highlights

Provena Will Share Artwork for Materials

Provena United Samaritans Medical Center Foundation in Danville is trying to reduce heart disease in women. Staff worked with its local women's health coalition to plan the elements of the campaign, Women's Heart Matters. The campaign includes educational programs, screenings and a multi-layered media campaign. Provena has developed glossy black and white materials newspaper ads, billboards, book marks and brochures that focus on diet, exercise and smoking. The artwork is public domain, since it is funded with OWH grant dollars.  For a small fee, you can get camera-ready art for the materials, with your agency's name dropped in. For more information, contact Chad Hays at 217-442-6300.

Kids Switched to Seat Belts Too Soon

Many parents are moving young children into seat belts too soon after they outgrow child safety seats. By doing so, parents are putting their children at a higher risk of serious injury in crashes, according to the first research into the subject. Young children who are buckled prematurely into adult seat belts that are not designed to fit them properly, are 3 « times more likely to suffer a significant injury and four times more likely to have serious head injuries in crashes than children who are properly restrained with booster or car seats. Proper restraint means using infant and convertible child safety seats for children younger than 4 and booster seats for children from 4 until about 9, when they fit properly in the vehicle seat belt. As explained by Dr. Dennis Durbin, co-author of the study highlighted in a recent Chicago Tribune article, "This research provides strong evidence that belt- positioning booster seats are a crucial safety step between car seats and adult seat belts."

A Growing Public Health Concern: Motor Vehicle-Related Injuries Among Older Adults As highlighted in a recent issue of the Morbidity and Mortality Weekly Report, researchers from CDC's National Center for Injury Prevention and Control gave a summary of 1990-1997 surveillance data from the National Highway Traffic Safety Administration on motor vehicle-related injuries and fatalities among older adults defined as adults 65 years and older. Results of the study showed that there was a 14 percent increase in the number of motor vehicle traffic-related fatalities and a 19 percent increase in the number of motor vehicle traffic-related nonfatal injuries between 1990 and 1997 among older adults. During the eight-year study period, traffic crashes accounted for approximately 55,000 deaths and 1,869,308 nonfatal injuries among older adults. In 1996, older adults represented 13 percent of the U.S. population and accounted for 17 percent of all motor vehicle-related deaths. Likewise, the female death rate from motor vehicle-related injuries rises sharply from 9.5 per 100,000 deaths in those 45-64 to 17.6 per 100,000 in the 65 and older age group.  Possible reasons for older adult's increased risk for motor vehicle-related injury include visual deterioration and declines in cognitive and motor skills. Susceptibility to injury in a crash is also increased by physical frailty. Thus, a crash that results in nonfatal injuries to a younger person might result in the death of an older adult driver or passenger. Prevention measures include improving vehicle design, improving visibility of road signs, installing median islands on wide roadways and screening/testing programs to help older drivers assess their abilities and to make decisions about driving.

[Editor's Note: In the event of a crash, air bags and seat belts will minimize injuries and prevent fatalities. In addition, the AARP holds 55 ALIVE driving classes to help motorists over 50 improve driving skills. Discounts on auto insurance are available to those completing the 55 ALIVE class.  To find the class nearest you, call 1-888-AARP-NOW (1-888-227-7669).]

For more information about this study, contact Ann Dellinger, Ph.D., at the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, 770-488-4652, www.amd1@cdc.gov .

 Eating Disorders Referral and Resource Guide

The new Eating Disorders Referral and Resource Guide for Illinois is available from the Office of Women's Health. This guide contains a description of each type of eating disorder and tips on ways to help someone who has an eating disorder. Also included is an alphabetic listing of organizations and professionals who can treat those with eating disorders. Copies may be ordered by calling the OWH Helpline, 1-888-522-1282, or faxing your request to 217-557-3326.

Student Internship in Women's Health Services

Student internships in women's health services are available. Those with a bachelor's degree in a related field and who are currently in a graduate program, or who recently received a graduate degree may be eligible to receive two weeks of mentoring from a leader in women's health services. To receive more information, please write Lippincott Williams & Wilkins, Attn: Susan Doan-Johnson, P.O. Box 1807, Horsham, PA 19044-9836. Sponsored by the National Association for Women's Health and Subaru of America.

Healthy Woman newsletter is published quarterly by the ILLINOIS DEPARTMENT OF PUBLIC HEALTH. Story ideas, suggestions and comments are welcome and should be forwarded to Lisa Keeler, Editor, Department's Office of Women's Health, 535 W. Jefferson St., Springfield, IL 62761; or call 217-524-6088.

George H. Ryan, Governor
John R. Lumpkin, M.D., M.P.H., Director
Illinois Department of Public Health
Sharon Green, Deputy Director
Office of Women's Health

Generally, articles in this newsletter may be reproduced in part or in whole by an individual or organization without permission, although credit should be given to the Illinois Department of Public Health. Articles reprinted in this newsletter may require permission from the original publisher.

The information provided in this newsletter is a public service. It is not intended to be a substitute for medical care or consultation with your health care provider and does not represent an endorsement by the Office of Women's Health. To be included on the mailing list, call 1-888-522-1282.

Please insert the following in box. See former newsletters.
Questions? Need Information? Materials? Referrals? Call the Women's Health Help Line.
1-888-522-1282

Mark your calendar for the following events sponsored by the Illinois Department of Public Health, Office of Women's Health

Southern Illinois Women's Health Day
"Women's Health Matters"
JUNE 16, 2001
Keller Convention Center
Effingham, Illinois
This event is FREE and open to the public, but advance registration is required!

Women's Health Conference
OCTOBER 23-24, 2001
Donald E. Stephens Convention Center
Rosemont, Illinois

Advance registration required.
For more information on either of the conferences mentioned above, contact the Office of Women's Health Helpline at 1-888-522-1282.