Cumulative Trauma

Disorders

ASSESSMENT AND MANAGEMENT

General features
 When a WMSD develops a worker
experiences:
 1. swelling, as tissues become irritated
 2. pain
 3. stiffness and loss of range of motion of
 surrounding joints
 4. inability to work and function at home
 aching
 tenderness
 swelling
 tingling or numbness
 loss of joint mobility
 weakness of loss of coordination in the hand
 crackling
 muscle spasms
 decreased coordination
 Clinical assessment, prognosis and return
to work with reference to work related
neck and upper limb disorders.

Hagberg M.
 OBJECTIVES: To describe the clinical
assessment and management of work related
neck and upper limb disorders
 RESULTS: The clinical assessment consists
of the clinical and exposure history, the
evaluation of the physical and laboratory
findings. The physical examination should
include the following steps:
 (1) inspection; (2) testing for range of motion
(3) testing for muscle contraction pain and
muscle strength (4) palpation of muscle
tendons and insertions and (5) specific tests.
 CONCLUSIONS: Despite the large number of
patients with neck and upper limb disorders
the scientific evidence for clinical
assessment, to determine the prognosis and
for successful procedures for return to work
are few.
A REVIEW OF DIAGNOSTIC
CRITERIA
FOR WORK-RELATED UPPER
LIMB DISORDERS
Carpal tunnel syndrome
 Provocation tests are principally .
 Tinel’s sign
 Phalen’s test
 Flick ‘s sign
 Carpal compression
 Electrophysiology is used to confirm the
diagnosis of carpal tunnel syndrome.
Reproducibility of clinical signs on
examination of the neck
 Muscle atrophy 0.48
 Muscle strength 0.47
 Muscle tenderness 0.43
 Sensitivity to light touch 0.63
 Sensitivity to pain 0.48
 Sensitivity to vibration 0.50
 Range of movement 0.48
Thoracic outlet syndrome
 The signs included a positive elevated arm
stress test
 Positive Morley’s sign
 Positive Adson’s test
 Roos’ test
 Adson’s manoeuvre is considered to be
unreliable and unspecific.
 diminution of radial pulse in response to
manoeuvres around the shoulder is of low
sensitivity and specificity and that if the
patient is operated on for this sign only then
improvement does not occur.
Conclusion
 A number of provocative tests have been
proposed but figures for sensitivity and
specificity are not available.
 Investigative procedures are often
inconclusive and unhelpful.
a) Pattern of occupational use consistent with
this syndrome (usually overhead work) and
an appropriate temporal relationship.
b) Neurogenic symptoms on the inner aspect of
the arm in ulnar nerve distribution or distally
in the ulnar or median nerve distribution
c)No evidence of distal nerve entrapment
electrophysiologically.
Shoulder
 The diagnosis of conditions around the
shoulder is very clear cut
Elbow
 The gold standard in epicondylitis must be the
response to treatment yet this is often
unsatisfactory, particularly when the patient
continues the aggravating movement.
 Diagnostic injections with a local anaesthetic
remain an immediate diagnostic aid, although
there is nothing in the literature to support
this.
cubital tunnel syndrome
 Hypaesthesia on testing with vibration,
monofilaments or 2 point discrimination would
be expected in the lateral aspect of the 4th
and 5th finger of the hand
 electrophysiological criteria are nerve
conduction velocity less than 35m/sec for the
ulnar nerve across the elbow
Pronator teres syndrome
 Provocative test is reproduction of pain on
resisted pronation of the forearm
 Electrophysiological testing is often
inconclusive.
Anterior interosseus nerve syndrome
 Muscles involved are: pronator quadratus,
flexor pollicis longus and/or flexor digitorum
profundus to the index finger.
 Unable to make an ‘0’ sign by pinching the
thumb and index finger together.
Wrist disorders
 Finkelstein’s test
 Localised pain and swelling over the muscle
and tendon with exacerbation of pain and
appearance of crepitus on resisted
movement.
Conclusion
 Pain, loss of function (ie: grip or pinch) and
signs including swelling, crepitus, warmth and
tenderness.
 Minimal criteria are: (a) pain appropriate to
occupational use (b) pain and tenderness
 Along the appropriate tendon (c) pain on
resisted movement of the muscle-tendon
complex.
Hypothenar hammer syndrome
 The diagnostic sign is Allen’s test.
Trigger finger
 Minimal criteria as clicking or catching of the
affected digit on movement.
 Signs are demonstrable triggering and
tenderness anterior to the metacarpal of the
affected digit.
Osteoarthritis
 Symptoms of pain, loss of movement and
early morning stiffness less than 30min.
 Signs include loss of movement and bony
enlargement.

 Radiological criteria are loss of joint space,

osteophytes, sub-chondral sclerosis and cyst
formation; occasionally erosions (loss of
cortical integrity over the surface of the joint) .
Dupuytren’s contracture
 Signs can vary from the finding of a small
nodule at the base of the ring finger at the
level of the distal palmar crease

 Thickening and tethering of the fingers,

particularly the little finger, in full flexion.
Non-specific syndrome of work-
related upper limb disorder.
 Pain in the arm
 Weakness, loss of strength, burning,
paraesthesiae,
 Cramp, tremor, incoordination
 Muscle tenderness, incoordination (finger
touch test), loss of grip/pinch strength
Non specific disorders

 Temporary symptoms of over-use such as fatigue or

soreness in the muscles after exercise
 Conditions in which there is persistent pain and
pathological changes with functional Ioss,eg:
tenosynovitis
 Primary fibromyalgia
 Generalised rheumatic diagnoses, eg: osteoarthritis
 A psychogenic component in which symptoms are
thought to be of psychological origin,eg: arm pain in a
depressed patient.
 There may be a paucity of physical signs in
non-specific WRULD.
Prevention
 Work site evaluation
 Education
 Implementation of an preventive plan
 Maintaining the program
Hand therapy evaluation
 History
 Current symptoms
 Pain status
 ADL status
Objective
 Range of motion
 Strength
 Volume
 Palpation
 Analysis of posture
 Work simulation
 Provocative tests
 Semmes weinstein test
 Vibrometry
 Stress tests
Functional grading of cumulative
trauma disorders
 Grade I – pain after activity
 Grade II-pain in one site while working
 Grade III-pain in one or more sites while
working
 Grade IV-all common uses of hand /upper
extremity gives rise to pain
 Grade V-loss of capacity to use hand
Phase I treatment
 Symptom control
 Pain spasm pain cycle
Strengthening
 Good circulation
 Regular movement
 Leverage and efficient force exertion
 Use of the right muscle for the task
 Adequate recovery
Work Hardening and Conditioning
 Historical overview
 Use graded tasks to progressively improve
thebiomechanical,neuromuscular,
cardiovascular/metabolic and psychosocial
function of the individual in conjunction with
real or simulated work activities
Concept
 Work oriented tasks to enhance performance
Increases stamina, endurance, physical
tolerance productivity and ultimately
confidence
Differentiating work hardening from other
therapy programs

 Work hardening and work conditioning

 Work hardening and work therapy, work

stimulation, situational assessment and
exercise programs
Current trends in treatment
 Evaluation and determination of candidacy:
1. Intake / initial interview
2. Subjective evaluation
3. Physical examination
4. Physical demand testing
5. Reevaluation
 Establishing treatment plan
 Problems and program
 Grading participation


Analysis and Design of Jobs

Job Documentation
 Work objective
 Work standard
 Work method
 Workplace layout
 Work equipment
 Materials
Source information
 Industrial engineering

 Personnel departments

 Engineering drawings and equipment manuals and

catalogs

 On site inspection

 Supervisor interviews and Worker interviews

 Rate the repetition of the job using: Ordinal
scale

 Perception of effort using : VAS

 Very high: body parts are in steady motion
difficult to keep up
 High: the worker might fall behind
 Medium :no difficulty
 Low :pauses
 Very low:occasional
 Reducing repetitiveness:

1. Work organization
2. Quality control and maintenance
3. Mechanical aids
Forceful Exertions

 Methods to estimate job force requirements:

1. Observation
2. Rankings
3. Ratings
4. Direct measurements
5. Calculations
6. Electromyography (EMG)
 Reductions of force requirements:

1. Friction enhancement, weight reduction

2. Mechanical assists
3. Balance of work object
4. Handle size and design
5. Torque control devices
6. Work rate
7. Work posture
8. Glove selection
9. Quality control and maintenance
Contact Stresses
 Control measures:

1. Enlarging handles
2. Rounding edges of handles and benches
3. Compliant handle materials
4. Tools for pounding
5. Padding the hand
Posture
 Identifying and recording stressful postures

 Control measures:

 Work location
 Work orientation
 Tool design
 Consideration for worker size
Vibration
 Causes
 Minimize exposure
Temperature
 Tenosynovitis

 Sensory, motor and circulatory impairments

 Effects of these impairment:

Ergonomics Program
 Key elements

 EVALUATION :
 Job analysis
 User feedback
 Implementation of new equipment
 Medical surveillance
References
 Chronic musculoskeletal injuries-Ranney
 Work related musculoskeletal disorders-
Barbara silverstein, Richard wells
 Work hardening-Linda
 JOSPT
 Rehabilitation of the hand-Hunter
 Ergonomics in health care and rehabilitation-
Berg rice