William Safire is quoted as saying, "Never assume the obvious is true." That premise was the motivation behind the first book by Suparna Damany, MSPT, CHT, CEAS, confidently titled It's Not Carpal Tunnel Syndrome!

"My work started focusing on repetitive stress injuries, and I realized that many of these cases involved misunderstood symptoms, misdiagnosed conditions, and—in some cases—misapplied surgery," Damany says. "I realized that the problem involved a lot of chronic muscle and nerve involvement, really involving the entire upper body, even when the symptoms very often were typical of carpal tunnel syndrome."

She stresses that those symptoms—usually tingling and numbness—are not exclusively in the domain of carpal tunnel syndrome and are, in fact, simply pieces that make up the puzzle of repetitive stress injuries (RSI).

"It really does involve the entire upper body, and I realized that, especially for long-term computer users, any other view would be quite short-sighted," she says. "It was my goal for the community to start incorporating this information into a pool of knowledge that would be effective in treating repetitive stress injuries. And the book was my contribution toward making that happen."

Differentiating between an ailment limited strictly to the wrist from one that radiates up the entire arm or into the neck and shoulder is the vital first step in identifying the correct treatment program, according to Damany.

"You have several areas of tightness in your body. The nerves pass through there, and so do the arteries," she says. "Any treatment will be highly ineffective if you treated just one body part."

To illustrate the point, Damany recalls a simple analogy she shares with patients.

"Imagine that the nerves, like a rubber band, are tethered in four or five different spots. If you just release one area, you will feel better temporarily, but that slack is going to quickly be taken up by all of the other areas holding that nerve down," she says. "Therefore, in terms of treatment, you have to address all of the pieces of the puzzle; you cannot simply say, 'You're a computer user and your wrist hurts, so it must be carpal tunnel syndrome.' "

Such a quick diagnosis ignores the fact that patients, even heavy computer users, are not solely employing their wrists during long hours in front of a monitor; the entire upper body is involved.

Instead, the pain may be caused by a neck problem that is causing symptoms in the arms. Or it could be a problem in the shoulder or elbow that is causing symptoms in the hand.

"It is not always a repetitive injury that causes it; A lot of times the pain comes from a static position, not necessarily repetitive work. It could be that sitting is the problem, not necessarily typing," she says. "So you cannot just treat the hand because the symptom is in the hands. That does not address the problem, nor does it provide any long-term relief."

A COMPLEX PROBLEM, A DYNAMIC SOLUTION

The fact that each case is a mystery—and that every single patient is different—is part of the appeal of hand therapy for Damany.

Even though there may be certain patterns you tend to see from patient to patient, each person's body will compensate in its own individual manner, she says. This makes treatment a bit more difficult, because there's not necessarily a protocol to follow like there is if you have a flexor tendon injury, for example.

Complicating matters is that RSI is a cumulative condition that tends to involve an increasing number of body parts the longer it exists. Exactly how the condition manifests itself is as individual as the person who is suffering from it.

"The same techniques may not necessarily work the same way on two different people. Their response is different, and as a result the treatment has to be very dynamic, it needs to change as the patient's body changes," says Damany, who emphasizes the role a hand therapist plays in creating a treatment regimen to meet the specific needs of each individual person. "I think there is more of an art to the treatment, as opposed to just being a science ... and that is what I enjoy."

Though there have been advancements in modalities used for hand therapy—such as electrical stimulation, ultrasound, and lasers—Damany still relies heavily on manual therapy.

"Manual therapy techniques are becoming more popular. Whereas a few years ago they would have gone into the bastion of 'alternative therapies,' now they're becoming more and more effective," she says. "And I think we are beginning to realize the value of the interaction between different areas of the body, which lead to certain conditions."

In addition to sharing with her peers what does work, Damany is just as passionate about dispelling some of the fallacies surrounding RSI, including the belief that the condition does not respond well to treatment.

"The main misconception is that it doesn't recover, and that's not true," she says. "It recovers beautifully with the right treatment."

SPREADING THE WORD

For the past 6 years, Damany has been on the board of the American Physical Therapy Association's Hand Rehabilitation Section. When she first joined the board, she wrote the section's newsletter, The Hand Prints, which is published five times per year. Two years ago Damany, as vice president, took over the role of program chair for the organization's Combined Sections Meeting (CSM), an annual conference that brings together programming designed by all 18 of APTA's specialty sections.

A big part of the Hand Rehabilitation Section's mission is to educate PTs about the specialty of hand therapy.

"Traditionally, it's the occupational therapist who becomes a hand therapist," Damany says. "But physical therapists are very well-versed in the hand, the upper extremities, the neck—it is a natural transition for physical therapists to become certified hand therapists, because the knowledge is already there."

In recent years, the number of PTs expressing interest in becoming hand therapists has increased. Damany attributes this trend to increased visibility of the specialty, as well as a better understanding that the field involves more than just the wrist and the hand.

"Now there is much more awareness that hand therapy really entails the upper quadrants—though it involves everything from the neck, the scapular area, and the upper extremities," she says. "And I think that is making hand therapy more appealing to physical therapists."

In addition to networking opportunities and a filled exhibit hall, CSM also strives to present a broad range of programming, because its membership includes everyone from student PTs to experienced hand therapists.

Damany listens to the members, reviewing evaluations from the prior year's CSM and following suggestions when possible.

"We ask them what they would like to see and what they are interested in learning about, and we try and incorporate that," she says. While they do try and address any of the industry's "hot topics," every meeting covers "a little bit of everything," providing information on the neck and shoulder area, as well as problems of the elbow, wrist, and hand.

Research is also a key component of CSM, with both the platform and poster presentations showcasing original research. Of particular interest to Damany are studies being conducted to determine the changes in the tissue and the blood flow in people who use their arms repetitively.

She's also interested in a study that is currently slated to be presented at the upcoming CSM that is attempting to link clinical depression with reduction in grip strength.

"The research is mostly done on animals at this point, but it is still very intriguing research. There is research in many areas going on, everything from tendon injuries to different kinds of fractures," Damany says, noting that modalities are constantly being fine-tuned as more research goes on and the parameters are better defined in terms of what is most suitable for certain conditions and certain parts of the body. "I definitely follow the RSI research because it is the research that guides clinicians ultimately. That is the base of everything else: all the treatment modalities that we know are effective, and new information that might help us better understand the clinical condition."

A PLACE OF HER OWN

Since 2000, Damany has also operated a successful physical therapy practice in Allentown, Pa, called Hands On Healing Physical Therapy Inc. Working alongside another full-time PT and a PT assistant, she says much of her work today revolves around developing treatment for individuals suffering from chronic pain.

"Although my practice has evolved into treatment of chronic pain of the upper extremities and upper body, along with general chronic pain, I still see people from all over the world who travel to me because of their repetitive stress injuries," Damany says.

As her book became more popular, she started to notice a shift in the types of patients she was seeing. Alongside the contingent of computer users were professional musicians, rock climbers, and hairdressers.

It seems the book, which was targeted at computer users—including a lot of ergonomics and prevention strategies and treatments specifically for them—has been embraced by people in all walks of life.

"There are definitely parallels between computer users and musicians and hairdressers and rock climbers," Damany says. "Anyone who really uses her body in a static position or who uses their other extremities in ways that we weren't meant to will eventually have the same problems. Our bodies are meant to move around, and we are using them in a very different way now than we did years ago."

Thanks to Damany's first publication—she is currently putting together a second book addressing chronic pain—her waiting room is filled not only with patients working toward health, but also with success stories.

Hands On Healing Physical Therapy treats patients from across the United States and all over the world. To acknowledge the great distance some people cover in search of relief, Damany created a special wall on which they place a flag representing each state or country a patient has traveled from.

"We easily have flags from more than 20 states and about 10 different countries," Damany says, naming off Denmark, Germany, the UK, and Israel. "When therapy is done, we also have clients make handprints and ask them to write a message on it."

The wall has some sentimental value to it, Damany admits.

"Because typically this is a long-term treatment, over time we get very friendly with our patients and we get to know them and their families, their lifestyles, their likes and dislikes—and we often just like to read the handprints and remember the patients we've treated and discharged."

But she also believes it serves a bigger purpose.

"When patients first come in, oftentimes they are skeptical and dejected, because nothing has worked and now they have had to put their lives on hold to come to Allentown to get treated," Damany says. "But when they walk in, they see the handprints and the wall shows them that there is so much hope."

Dana Hinesly is a contributing writer to  Physical Therapy Products. For more information, contact .