Transcript Greetings from University of Southampton Cumulative Trauma Disorders: Their Recognition and Ergonomic Considerations By Dr.

Greetings from University of
Southampton
Cumulative Trauma Disorders: Their
Recognition and Ergonomic
Considerations
By
Dr. Bhoomiah Dasari, PhD, DBA, MSc, FACOT
School of Health Professions &Rehabilitation Sciences
University of Southampton
U.K.
Cumulative Trauma Disorder
(CTD)
• Repetitive Stress Injury (RSI)
Cumulative: injury develop
gradually over period of time
Trauma: bodily injury from
mechanical stresses
Disorder: physical ailments or
abnormal conditions
Scope of Ergonomic Injuries
•CUMULATIVE TRUAMA DISORDERS
(CTD): These are health disorders
arising from repeated biomechanical
stress.
•CTD involves damage to the tendons,
tendon sheaths, related bones,
muscles, and nerves of:
•Hands, wrists, elbows,
shoulder, neck, and back.
Pathology
Overuse
Mechanically
Tears of
ECRB
Physiologically
Adaptive change
in tissue
Tendon
deformation
Thickening of
tendon sheath
Permanent pathology
Pathology -- Mechanism
Repetitive Motion
Relaxation
 Tension
 Wear & Tear
 Repair ability
Force Exertion
Microtears
 Pull on tendon
Compress joint
Tissue ischemia
 Removal rate
Further Tear
Inflammation
Risk Factors
• Force
• Repetition
• Posture
• Duration
• No rest
• Personal factor:
• anatomical build-up, working
habit(work or household)
Changes in Soft Tissue
• Circulation : ischemia
• Mechanical deformation
• Tiny tear & micro-trauma
• Inflammation & scar formation
• Nerve compression
Common Disorders
• Tendon : Tendinitis ,Tenosynovitis,
etc.
• Nerve disorder : entrapment,
compression, etc.
• Neurovascular disorder : Thoracic
Outlet Syndrome
Management : Principles
1. Exclude systemic disease
2. Recognize and eliminate aggravating
factors
3. Provide an explanation to patient
4. Provide instruction in self-help exercise
5. Provide relief from pain
6. Project an expected outcome
Management : General
• Pain relief modalities
TENS, Splintage, Tubigrip, Heat/cold
• Speed up healing process/scar
management
Resting, Ultrasound, massage
• Preventive/Protective
Working splint, Ergonomic Advice &
Device, patient education, Stretching
ex., Rest & Exercise
Patient Education
• Pathology of condition
• Risk factor that lead to their CTD
problem
• clear presentation of how pt. can
participate in their management. eg.
use of splint and work modification
• motivate patient to accept the concept
of work ergonomics
Ergonomics
From the Greek Words
Ergos (Work) and
Nomos (Law),
Ergonomics is the Law of Work
ERGONOMICS:
The study of the design of work in
relation to the physiological and
psychological capabilities of people
(matching the work place to the
worker)
Work Ergonomics
• Job analysis
• Risk factors identification
• Work habit and layout modification
• health concept of people
Cumulative Trauma Disorders
of the Upper Limb
• Tendinitis
• Lateral Epicondylitis (Tennis Elbow)
• Golfer’s Elbow
• Carpal Tunnel Syndrome
• Cubital Tunnel Syndrome
• De Quervain’s tenosynovitis
Tendinitis
•Tendinitis is a form of tendon
inflammation that occurs when a
muscle/tendon unit is repeatedly
tensed.
•Tendon becomes thickened,
bumpy and irregular
Tennis Elbow
• Lateral Tendinitis of Common
Extensor Origin
Cumulative trauma disorder
Characteristics of develop:
 Multifactorial
 Long time development
(Grieco, 1998)
Tennis Elbow
• Lateral Epicondylitis
• acute, intermittent, subacute or
chronic
• c/o pain during grasping or
supination of wrist
• c/o difficult in pick up a teapot
Tennis Elbow: Assessment
• Resting pain
• Local tenderness: lateral
epicondyle, extensor
muscle belly
• Stretch test
• Middle finger test
• Stress test: wrist
extensor and supinator
• Power grip
• ADL
Tennis Elbow : Management
• Tennis Elbow Band
• Tubigrip
• Local injection
• Heat/cold
• Stretching Exercise
• Strengthening
Exercise
TE Band: General Mechanism
(Meyer et.al, 2002)
• Inhibit muscle expansion
• magnitude of muscle contraction
• tension at the musculotendinous
unit proximal to the band
• Supplying the extensor muscle mass
with a second origin distal to the
radial head
Effect of TE bands
• Caused reduction in
electromyographic activity
(Meyer
et.al, 2002)
• Objective improvement in wrist
extension & grip strength (Nirschl,
1999)
• Increased pain threshold
(Chan, 2002)
Standard TE bands
(Counterforce brace)
• Forearm strap (Kasdan, 1997)
• Greatest use in either
• mild case
• persistent minor discomfort
• Not sufficient for the acutely painful elbow
Wharfedale
Clasp (Cooke,
1999)
thermoplastic materials
individual sizing
available
Effective & longlasting
Overall relief & improved
function
Tennis Elbow : Patient education
Highlight
• Lifting and carrying habit
• mopping floor
• cleansing window
• twisting towel
• holding cooking pan
• washing clothes
Tennis Elbow: Complications
• Golfer’s elbow or other CTD
conditions e.g. CTS
• synovitis of elbow joint
• muscle pain of biceps, triceps
• associated with CTS
Golfer’s Elbow
Golfer’s Elbow: Assessment
• Resting pain
• Local tenderness: medial
epicondyle, flexor muscle belly
• Stress test: wrist flexion, pronation
• Power grip
• ADL
Golfer’s elbow: Management
• Golfer’s elbow
band
• Tubigrip
• Stretching ex.
• Strengthening ex.
• Patient education
• Work ergonomic
advice
Tenosynovitis and Stenosing
Tenosynovitis
•Tenosynovitis
•Synovial sheath is stimulated to
produce excessive amounts of
synovial fluid. The excess fluid
accumulates and the sheath becomes
swollen and painful
•Stensosing Tenosynovitis
•Stensosis refers to a progressive
constriction of the tendon sheath
De Quervain’s disease
Abductor pollicis longus
Extensor pollicis brevis
De Quervain’s Disease
De Quervain’s disease
• Stenosing
tenosynovitis
• Abductor pollicis
longus and extensor
pollicis brevis
De Quervain’s disease:
Assessment
• Resting Pain
• Local Tenderness
• Stress Test:
Extension(EPB),
Abduction(APL)
• Finkelstein Test
• Power grip
Sharp pain
De Quervain’s disease:
Complication
• Osteoarthritis of 1st CMC jt.
• Tendinitis of wrist extensors
• ganglia
• radial sensory nerve entrapment
(burning pain)
De Quervain’s disease:
Management
• Splintage
 Night Splint: Static, wrist in
cock-up 20°, thumb in mid
opposition, IP extend.
 Working Splint: Soft
Regime:
 Acute- 24 hr. static splint x
1wk --> change to night with
day working splint
 Chronic- static night splint x
2wk with working splint.
De Quervain’s disease:
Management
• Intralesional
corticosteroids
injection
• Ultrasound
treatment
• Friction massage
De Quervain’s disease:
Management
Extensor carpi radialis
longus and brevis tendons
.
• Surgical
intervention
Extensor pollicis
Extensor longus tendon
pollicis brevis
tendon
.
Sensory branch of the
radial nerve
.
Abductor
pollicis longus
tendon
De Quervain’s: Patient education
Highlight
• pick up large object by using 1st
web
• forceful pinch action
• use of scissors, cutter
• open bottle
• grocery shopping
• holding pen
Carpal Tunnel Syndrome
CTS
• Carpal tunnel: flexor
tendons with sheaths,
median nerve adjacent
vessels
• pain and paresthesia,
awakening numbness,
weakness of thenar
muscles
• Etiology: change in
tunnel size, local and
systemic disease,
nutrition, pregnancy,
habit
CTS: Assessment
•
•
•
•
•
•
•
•
•
•
Night pain/numbness
Paresthesias
Stretch Test
Thenar atrophy
Tinel sign
Phalen’s test
Wrist ROM
Moving 2pd
Power and pinch
ADL
CTS: Management
• Splintage : night & day splint
• Patient education: Ergonomic
advice
• Local injection
• Surgical intervention: open release,
endoscopic release.
CTS: Splintage program
• Night cock-up
splint: <
flexion 20° -neutral -- <
extension 20 °
• Day working
splint
CTS : Patient Education
• Knitting
• Sewing
• Household task: Cleansing work,
grocery shopping, etc.
• Clerical work: typing using mouse,
phone answering, etc.
• Proper wrist position in tools handling
CTS: Surgical Intervention
• Open release + Camitz transfer
.
.
Palmar
fascia
Palmar
branch
of the
median
nerve
Motor
branch of the
median nerve
Transferred
palmar fascia
Opening of the
carpal tunnel
Palmaris longus
tendon
.
CTS: Complication
• Guyon’s canal
compression
 lies beneath volar
carpal ligament
and pisohamate
ligament; its
radial distal wall
is the hook of the
hamate;, its
proximal ulnar
wall is the
pisiform
Sensory
branch
Motor branch
Hook of hamate
Pisiform bone
Ulnar nerve
Ulnar artery
Volar carpal ligament
(covering the ulnar
artery and nerve)
Transverse
carpal lig.
Guyon’s canal
Tubercle of scaphoid
Median nerve
Palmar carpal lig.
Flexor carpi
radialis tendon
Cubital Tunnel Syndrome
Cubital Tunnel Syndrome
• Ulnar nerve
entrapment at
forearm
• pain and
paresthesia along
lateral forearm,
wrist, 4th and 5th
fingers
• weakness of
intrinsic
• Tinel at the site of
entrapment
Incision
Constriction band Pseudoneuroma
of the ulnar nerve
(Osborne)
Cubital Tunnel Syndrome:
Management
• Work modification
• Elbow padding
• Surgical intervention
Key to Success
• Correct diagnosis
• Identify risk factor accurately
• Work ergonomic advice should be
applicable to the work place of
patients.
• Patient’s motivation and
participation
• Therapist’s skill and understanding
of CTD
Ergonomic Measures to avoid CTD:
Education
• Aim:
• Reduce exposure to risk factors
• Method
• Tools and working environment modification
• Use of proper tools e.g. increase size of grip
− Office worker - ergonomics of computer station e.g.
forearm support
• Rearrangement of habit & daily routine
− Reschedule frequency, duration and intensity of tasks,
− Housewife – spread household tasks throughout whole
day
Ergonomic Measures to avoid CTD:
Education
• Aim: Reduce exposure to risk factors
• Method
• Proper lifting posture
• Recommendation of ½ max lifting weight
• Heavy work workers
− ~ 50% of maximum lifting capacity by lifting
assessment
Ergonomic Considerations:
Posture
Ergonomic considerations:
use of hands
Ergonomically Designed Products
Ergonomically Designed Products
Ergonomically Designed Products
Continuous Education
• Review pathology & symptoms
• Reinforce application of techniques
taught in daily lives
• Review warning sign
• Fatigue pain in forearm
• Early intervention
• symptoms reappear
Conclusion
•In
my opinion, there is nothing new about
cumulative disorders.
•Only the problems have changed as new industries
appear and old ones disappear.
•An integrated approach with a well-trained physician
orchestrating MDT concept is necessary.
•Work station ergonomics should be corrected and
conservative treatment instituted first if possible.
•Surgical care should be done only by a well-trained
hand surgeon and followed by a skilled hand
therapists.
Acknowledgement
•My sincere gratitude goes to the following
without their support, it would not have been
possible to participate in this congress:
•The University of Southampton, England,
U.K.
•Biometrics Ltd, U.K.
References
1.
2.
3.
4.
5.
6.
Chan, H. L. (2002), Effect of Counterforce Forearm Bracing
on Wrist Extensor Muscles Performance. American Journal
of Physical Medicine and Rehabilition.
Dimberg, L. (1987). The prevalence and causation of tennis
(later humeral eipicondlylitis) in a population of workers in
an engineer industry. Ergonomics, 30, 573-580.
Grieco, A., Molteni, G., Vito, G. D. & Sias, N. (1998).
Epidemiology of musculoskeletal disorders due to
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Hunter, J. M. (1995). Rehabilitation of the hand: surgery
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Jacobs, K. (1999). Ergonomics for therapist. Boston, MA :
Butterworth-Heinemann.
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Their recognition and ergonomics measures to avoid them.
Applied Ergonomics, 20, 274-280.
References
7.
Mayer, T.G., Gatchel, R.J. & Polatin, P.B. (2000)
Occupational Musculoskeletal Disorder: Function,
Outcome & Evidence. USE: Lippincott.
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tennis elbow tendinosis. In B.F., Morrey, the elbow and
its disorders (pp.523-535). Philadelpha: W.B.
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Thank You