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Journal of Back and Musculoskeletal Rehabilitation -1 (2017) 1–4 1

DOI 10.3233/BMR-150266
IOS Press

Cumulative trauma disorders: A review

Zaheen A. Iqbal∗ and Ahmad H. Alghadir
Rehabilitation Research Chair, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia

Abstract.
BACKGROUND: Cumulative trauma disorder (CTD) is a term for various injuries of the musculoskeletal and nervous systems
that are caused by repetitive tasks, forceful exertions, vibrations, mechanical compression or sustained postures. Although there
are many studies citing incidence of CTDs, there are fewer articles about its etiology, pathology and management.

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OBJECTIVE: The aim of our study was to discuss the etiology, pathogenesis, prevention and management of CTDs.
METHODS: A literature search was performed using various electronic databases. The search was limited to articles in English

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language pertaining to randomized clinical trials, cohort studies and systematic reviews of CTDs.
RESULTS: A total of 180 papers were identified to be relevant published since 1959. Out of these, 125 papers reported about its

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incidence and 50 about its conservative treatment.
CONCLUSIONS: Workplace environment, same task repeatability and little variability, decreased time for rest, increase in
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expectations are major factors for developing CTDs. Prevention of its etiology and early diagnosis can be the best to decrease its
incidence and severity. For effective management of CTDs, its treatment should be divided into Primordial, Primary, Secondary
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and Tertiary prevention.

Keywords: Cumulative trauma disorder, work related musculoskeletal disorders

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1 1. Introduction and fewer wastes are removed from the muscles, blood 18
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vessels, spinal discs and skin [7]. These disorders are 19

2 Cumulative trauma disorders (CTDs), an umbrella painful and sometimes crippling and the condition of 20
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3 term for various injuries of the musculoskeletal and whole body deteriorates [8]. They develop gradually 21

4 nervous systems that may be caused by repetitive tasks, over a period of weeks, months and years [9]. They can 22
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5 forceful exertions, vibrations, mechanical compression also result from other work activities that involve repet- 23

6 (pressing against hard surfaces), or sustained or awk- itive motions or sustained awkward positions such as 24
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7 ward positions [1,2]. These are referred by variety of sports or hobbies [1]. 25

8 terms like Repetitive motion disorders, Overuse syn- Compared to incidence of CTDs, there are fewer 26

9 drome, Regional musculoskeletal disorders, Repeti- articles about its etiology, pathology and manage- 27

10 tive motion injuries, Repetitive strain injuries, Occupa- ment [10]. The aim of our study was to discuss the eti- 28

11 tional strain/trauma, etc. [3,4]. Work related neck and ology, pathogenesis, prevention and management and 29

12 upper limb disorders were first described by Ramazz- of CTDs. 30

13 ini in 1713 and with the last two decades of industrial-

14 ization, its incidence has remarkably increased [1,5,6].
15 Such disorders are common in sedentary jobs, when 2. Methods 31

16 the body is still, as the circulation is slowed and as

17 a result fewer nutrients are delivered to the muscles A literature search was performed using various 32

electronic databases including Cinhal, Cochrane li- 33

∗ Corresponding author: Zaheen A. Iqbal, Rehabilitation Research

brary, Google scholar, Medline and Pub MED. Key 34

words used were “cumulative trauma disorders” 35

Chair (RRC), King Saud University, P.O. Box 10219, Riyadh 11433,
Saudi Arabia. Tel.: +966 569086528; Fax: +966 14693589; E-mail: AND/OR “prevention”, “etiology”, “pathology” and 36

z_iqbal001@yahoo.com. “conservative treatment”. References of obtained ar- 37

ISSN 1053-8127/17/$35.00
c 2017 – IOS Press and the authors. All rights reserved
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2 Z.A. Iqbal and A.H. Alghadir / Cumulative trauma disorders: A review

Table 1 Table 3
Levels of evidence adapted from center of evidence based medicine, Clinical characteristics of Cumulative trauma disorders (CTDs)
Oxford, UK (2010)
Symptoms of CTDs
Level Study • Pain (localized or during movement)
Level I Randomized controlled trials and systematic re- • Click or catching of affected digit during movement
views of level i studies • Swelling
Level II Prospective cohort studies and systematic reviews • Numbness or tingling
of level ii studies • Stiffness (decreased joint motion)
Level III Retrospective cohort studies and systematic reviews • Headache
of level iii studies • Radiation of pain or burning
Level IV Case series • Redness
Level V Expert opinion • Weakness or clumsiness

Table 2 Other reported factors include workplace environ- 64

Papers using different databases
ment, same task repeatability and little variability, de- 65

Database Number of papers creased time for rest, increase in expectations, in- 66
Cinhal 25 creased mechanization, ageing work force, reduction 67

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Cochrane library 10
Google scholar 45
in staff turnover and increased awareness of the prob- 68

Medline 10 lem [14–16]. Psychological and social status of the 69

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Pubmed 90 worker patient may also exaggerate the condition of 70

patients and domestic factors have role in presentation

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71

38 ticles were also examined for cross references. The of these disorders [17].
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39 search was limited to articles in English language per-

40 taining to randomized clinical trials, cohort studies and
systematic reviews (at least level IV evidence) of CTDs 5. Symptoms of cumulative trauma disorders
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41 73

42 (Table 1).
Symptoms of CTDs depend on pathology and part 74
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of the body involved [18]. Depending on condition, 75

43 3. Results symptoms may involve specific body parts including 76

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back, shoulder, elbows, hips, knees, wrist or fingers 77

44 After elimination of duplicated papers, a total of 180 and may present variety of symptoms [9,15,19]. (Ta- 78
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45 papers were identified to be relevant published since ble 3) Many workers do not experience symptoms until 79

46 1959 (Table 2). Out of these, 125 papers reported about several weeks, months or even years of exposure [1]. 80
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47 its incidence and 50 about its conservative treatment.

48 Of late there have been no reports or reviews about the
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49 types of CTDs or its etiology, biomechanics, manage- 6. Common cumulative trauma disorders 81

50 ment and prevention.

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51 We focus on four parts, factors contributing to the Back is most commonly involved in CTDs, but in- 82

52 development of CTDs, its symptoms, common disor- volvement of upper limb is growing fast [1,14]. How- 83

53 ders and management. ever, more than one body part can be involved simulta- 84

neously [20]. Various common CTDs have been listed 85

in Table 4 (list is inclusive but not exhaustive). One 86

54 4. Factors leading to cumulative trauma disorders problem can lead to another problem that may not be 87

directly due to risk factor associated with CTDs. E.g. 88

55 Work and non-work activities may together con- Inflammation in tendinitis can further lead to develop- 89

56 tribute to CTDs [11]. Poor or abnormal posture, awk- ment of impingement. 90

57 ward positions or movement of head, neck and upper

58 extremity [3] are most common factors that result in
59 increased pressure around specific nerves [12] leading 7. Management of cumulative trauma disorders 91

60 to compression. These can also lead to muscles be-

61 ing maintained in shortened position leading to their Prevention of etiology of CTDs, early diagnosis 92

62 tightness or some muscles being underused and weak- and intervention has been identified as the best man- 93

63 ened [13]. agement strategy to decrease its incidence, severity 94

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Z.A. Iqbal and A.H. Alghadir / Cumulative trauma disorders: A review 3

Table 4
Common cumulative trauma disorders
Tendon disorders Muscular disorders Peripheral nerve entrapment Joint/joint capsule disorders Neurovascular/vascular disorders
Tendonitis Focal dystonia Carpal tunnel syndrome Osteoarthritis Hand-arm vibration syndrome
(Raynauds’ syndrome)
Tenosynovitis Fibromyositis Guyon tunnel syndrome Bursitis Ulnar artery thrombosis
Stenosing Tension-neck Radial tunnel syndrome Synovitis Thoracic outlet syndrome
tenosynovitis syndrome
Peritendonitis Myositis Pronator teres syndrome Adhesive capsulitis Brachialgia
Ganglion cyst Myalgia Cubital tunnel syndrome Cervical syndrome Cervical radiculopathy
Epicondylitis Muscle shortening Sciatic neuritis Facet joint syndrome
(lateral or medial) and overuse (locking)

95 and improve prognosis [20]. Clinicians have a crucial – Proper posture for work i.e. ergonomic ad- 133

96 role in its early diagnosis and in stimulating appropri- vice – Careful positioning of body decreases 134

97 ate ergonomic interventions to reduce their incidence likelihood of injury. This can be done by ad- 135

98 and severity [1]. Although some disorders included in justment of existing furniture or replacing it 136

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99 CTDs are easy to treat (ganglion, arthritis, tendinitis), allowing for correct working postures. For 137

100 other nonspecific disorders pose a great challenge [3]. this purpose, concerned government depart- 138

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ments have prescribed specification of chairs, 139
101 7.1. Functional assessment desks, visual display terminal (VDT) and other 140

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equipment, including key features like wide 141
102 Detailed medical and occupational history and sub-
and deep chairs, with round edges that are ad-
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103 jective and objective physical examination is important
104 to diagnose CTDs [1]. To assess the effect of CTDs on justable without tools, Chairs backrests with 143

lumbar support which are adjustable in height, 144

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105 the performance of the workers there are various scales
106 available that numerically grade the amount of pain, etc. [21]. 145

disability, etc. to know how much these can effect on – Prescription of preventive exercises to be in- 146
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107

108 performance of the person [18]. Once a CTD has been cluded in daily routine. These may include 147

109 diagnosed, work assessment is important for its further relaxation, stretching and range of motion 148
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110 prevention and treatment. exercises. Such exercises increase the blood 149

flow, maintain muscle flexibility and joint in- 150

7.2. Prevention and treatment tegrity [23,25].

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111 151

3. Secondary prevention, which is action taken to 152

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112 For successful elimination and management of

halt the progress of a disease at its incipient 153
113 CTDs, this can be divided into following stages.
stage to prevent further complications. It in- 154
1. Primordial prevention, which includes preven-
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114
cludes diagnosis specific interventions including 155
115 tion of development of risk factors. Elimination rest from aggravating factors [1], disease specific 156
116 of harmful style of working through individual
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ergonomic advice, prescription of orthotics like 157

117 and/or mass education and ergonomic interven-
cervical collar, belts, etc. [20], anti-inflammatory 158
118 tion has been shown to be most effective in con-
agents like cryotherapy or medicines, steroids 159
119 trolling CTDs [21,22]. Job redesigning can re-
(10) and/or Physiotherapy/Occupational ther- 160
120 duce excessive muscle tension, grip force, joint
apy [23]. Surgery is the option where conserva- 161
121 movements, etc. to make work environment more
tive treatment fails [8]. Counselling plays an im- 162
122 favorable [23]. Various countries have adopted
123 national strategies to prevent development of portant role in the social and vocational rehabili- 163

124 CTDs which has major emphasis on Primordial tation of the patient [26,27]. 164

125 prevention [6,14,24]. 4. Tertiary prevention that is Intervention in late 165

126 2. Primary prevention, which includes action taken pathogenic phase to reduce or limit resulting im- 166

127 prior to the onset of disease, which removes pairment and disability, to decrease suffering and 167

128 the possibility that the disease will occur. This to promote patients adjustment to irremediable 168

129 promotes general health and quality of life by conditions. This can be done through psycho- 169

130 specific protective measures through population logical support and counselling, advice on job 170

131 mass strategy and high risk strategy by change, proper treatment according to complica- 171

132 prescribing- tions and rehabilitation [21,26–28]. 172

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4 Z.A. Iqbal and A.H. Alghadir / Cumulative trauma disorders: A review

173 8. Conclusion [13] Jackson MJ, Jones DA, Edwards RH. Experimental skeletal 224
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