Cumulative Trauma 2

8/8/2019 Cumulative Trauma 2

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Cumulative Trauma

Disorders

ASSESSMENT AND MANAGEMENT


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General features

When a WMSD develops a worker

experiences:

1.swelling, as tissues becomeirritated

2.pain

3.stiffness and lossofrangeofmotionof

surrounding joints

4.inability to work and function at home


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aching

tenderness

swelling

tinglingornumbness lossof joint mobility

weaknessoflossofcoordinationin thehand

crackling

musclespasms

decreased coordination


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Clinical assessment, prognosis and return

to work with reference to work related

neck and upper limb disorders.

Hagberg M.


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OBJECTIVES: To describe theclinical

assessment and management ofworkrelated

neck and upperlimb disorders


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RESULTS: Theclinical assessment consists

oftheclinical and exposurehistory, the

evaluationofthephysical and laboratory

findings. Thephysicalexaminationshouldinclude thefollowingsteps:

(1)inspection;(2) testingforrangeofmotion

(3) testingformusclecontractionpain and

musclestrength(4)palpationofmuscle

tendons and insertions and (5)specific tests.


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CONCLUSIONS: Despite thelargenumberof

patients withneck and upperlimb disorders

thescientificevidenceforclinical

assessment, to determine theprognosis andforsuccessfulproceduresforreturn to work

arefew.


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A REVIEW OF DIAGNOSTIC

CRITERIA

FOR WORK-RELATED UPPERLIMB DISORDERS


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Carpal tunnel syndrome

Provocation tests areprincipally .

Tinelssign

Phalens test

Flick ssign

Carpalcompression


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Electrophysiology isused toconfirm the

diagnosisofcarpal tunnelsyndrome.


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Reproducibility of clinical signs on

examination of the neck

Muscle atrophy 0.48

Musclestrength 0.47

Muscle tenderness 0.43

Sensitivity tolight touch 0.63

Sensitivity topain 0.48

Sensitivity tovibration 0.50

Rangeofmovement 0.48


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Thoracic outlet syndrome

Thesignsincluded a positiveelevated arm

stress test

Positive Morleyssign

Positive Adsons test

Roos test


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Adsonsmanoeuvreisconsidered to be

unreliable and unspecific.

diminutionofradialpulseinresponse to

manoeuvres around theshoulderisoflowsensitivity and specificity and that if the

patient isoperated onforthissignonly then

improvement doesnot occur.


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Conclusion

A numberofprovocative testshave been

proposed but figuresforsensitivity and

specificity arenot available.

Investigativeprocedures areofteninconclusive and unhelpful.


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a)Patternofoccupationaluseconsistent with

thissyndrome(usually overhead work) and

an appropriate temporalrelationship.

b) Neurogenicsymptomson theinneraspect of

the arminulnarnerve distributionordistally

in theulnarormediannerve distributionc)Noevidenceofdistalnerveentrapment

electrophysiologically.


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Shoulder

The diagnosisofconditions around the

shoulderisvery clearcut


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Elbow

Thegold standard inepicondylitismust be

theresponse to treatment yet thisisoften

unsatisfactory,particularly when thepatient

continues the aggravatingmovement. Diagnosticinjections with a local anaesthetic

remain animmediate diagnostic aid, although

thereisnothingin theliterature tosupport

this.


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cubital tunnel syndrome

Hypaesthesia on testing withvibration,

monofilamentsor2 point discrimination would

beexpected in thelateral aspect ofthe4th

and 5thfingerofthehand electrophysiologicalcriteria arenerve

conductionvelocity less than35m/secfor the

ulnarnerve across theelbow


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Pronator teres syndrome

Provocative test isreproductionofpainon

resisted pronationoftheforearm

Electrophysiological testingisoften

inconclusive.


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Anterior interosseus nerve syndrome

Musclesinvolved are:pronatorquadratus,

flexorpollicislongus and/orflexordigitorum

profundus to theindexfinger.

Unable tomake an 0sign by pinching the

thumb and indexfinger together.


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Wrist disorders

Finkelsteins test

Localised pain and swellingover themuscle

and tendon withexacerbationofpain and

appearanceofcrepitusonresistedmovement.


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Conclusion

Pain, loss of function (ie: grip or pinch) and

signs including swelling, crepitus, warmth and

tenderness.

Minimal criteria are: (a) pain appropriate tooccupational use (b) pain and tenderness

Along the appropriate tendon (c) pain on

resisted movement of the muscle-tendon

complex.


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Hypothenar hammer syndrome

The diagnosticsignisAllens test.


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Trigger finger

Minimalcriteria asclickingorcatchingofthe

affected digit onmovement.

Signs are demonstrable triggering and

tenderness anterior to themetacarpaloftheaffected digit.


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Osteoarthritis

Symptomsofpain,lossofmovement and

early morningstiffnessless than30min.

Signsincludelossofmovement and bony

enlargement.

Radiologicalcriteria arelossof joint space,

osteophytes,sub-chondralsclerosis and cystformation;occasionally erosions(lossof

corticalintegrity over thesurfaceofthe joint).


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Dupuytrens contracture

Signscanvary from thefindingofa small

nodule at the baseoftheringfingerat the

levelofthe distalpalmarcrease

Thickening and tetheringofthefingers,

particularly thelittlefinger,infullflexion.


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Non-specific syndrome of work-

related upper limb disorder.

Painin the arm

Weakness,lossofstrength, burning,

paraesthesiae,

Cramp, tremor,incoordination

Muscle tenderness,incoordination(finger

touch test),lossofgrip/pinchstrength


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Non specific disorders

Temporary symptomsofover-usesuch asfatigueor

sorenessin themuscles afterexercise

Conditionsin which thereispersistent pain andpathologicalchanges withfunctional Ioss,eg:

tenosynovitis

Primary fibromyalgia

Generalised rheumatic diagnoses,eg:osteoarthritis A psychogeniccomponent in whichsymptoms are

thought to beofpsychologicalorigin,eg: armpainin a

depressed patient.


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Theremay be a paucity ofphysicalsignsin

non-specificWRULD.


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Prevention

Worksiteevaluation

Education

Implementationofanpreventiveplan

Maintaining theprogram


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Hand therapy evaluation

History

Current symptoms

Painstatus

ADL status


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Objective

Rangeofmotion

Strength

Volume

Palpation

Analysisofposture

Worksimulation


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Provocative tests

Semmes weinstein test

Vibrometry

Stress tests


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Functional grading of cumulative

trauma disorders

Grade I pain afteractivity

Grade II-paininonesite while working

Grade III-paininoneormoresites while

working

Grade IV-allcommonusesofhand /upper

extremity givesrise topain

GradeV-lossofcapacity tousehand


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Phase I treatment

Symptomcontrol

Painspasmpaincycle


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Strengthening

Good circulation

Regularmovement

Leverage and efficient forceexertion

Useoftheright musclefor the task

Adequaterecovery


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WorkHardening and Conditioning

Historicaloverview


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Usegraded tasks toprogressively improve

thebiomechanical,neuromuscular,

cardiovascular/metabolic and psychosocial

functionoftheindividualinconjunction withrealorsimulated work activities


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Concept

Workoriented tasks toenhanceperformance

Increasesstamina,endurance,physical

toleranceproductivity and ultimately

confidence


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Differentiating work hardening from other

therapy programs

Workhardening and workconditioning

Workhardening and work therapy, work

stimulation,situational assessment and

exerciseprograms


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Current trends in treatment

Evaluation and determinationofcandidacy:

1. Intake/initialinterview

2. Subjectiveevaluation

3. Physicalexamination

4. Physical demand testing

5. Reevaluation


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Establishing treatment plan

Problems and program

Gradingparticipation


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Analysis and Design of Jobs


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Job Documentation

Workobjective

Workstandard

Workmethod

Workplacelayout

Workequipment

Materials


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Source information

Industrialengineering

Personnel departments

Engineering drawings and equipment manuals and

catalogs

Onsiteinspection

Supervisorinterviews and Workerinterviews


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Rate therepetitionofthe job using:Ordinal

scale

Perceptionofeffort using:VAS


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Very high: body parts areinsteady motion

difficult tokeepup

High: the workermight fall behind

Medium:no difficulty

Low :pauses

Very low:occasional


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Reducingrepetitiveness:

1. Workorganization

2. Quality control and maintenance

3. Mechanical aids


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Forceful Exertions

Methods toestimate job forcerequirements:

1. Observation

2. Rankings

3. Ratings

4. Direct measurements

5. Calculations6. Electromyography (EMG)


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Reductionsofforcerequirements:

1. Frictionenhancement, weight reduction2. Mechanical assists

3. Balanceofworkobject

4. Handlesize and design


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5. Torquecontrol devices

6.Workrate

7.Workposture

8. Gloveselection

9.Quality control and maintenance


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Contact Stresses

Controlmeasures:

1. Enlarginghandles

2. Roundingedgesofhandles and benches3. Compliant handlematerials

4. Toolsforpounding

5. Padding thehand


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Posture

Identifying and recordingstressfulpostures

Controlmeasures:

Worklocation

Workorientation

Tool design

Considerationforworkersize


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Vibration

Causes

Minimizeexposure


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Temperature

Tenosynovitis

Sensory,motorand circulatory impairments

Effectsoftheseimpairment:


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Ergonomics Program

Key elements

EVALUATION :

Job analysis

Userfeedback

Implementationofnew equipment

Medicalsurveillance


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References

Chronicmusculoskeletalinjuries-Ranney

Workrelated musculoskeletal disorders-

Barbara silverstein, Richard wells

Workhardening-Linda

JOSPT

Rehabilitationofthehand-Hunter

Ergonomicsinhealthcare and rehabilitation-Bergrice

Documents

Cumulative Trauma 2