cumulative trauma disorder by Hemant Nandgaonkar

CUMULATIVE TRAUMA DISORDER

CUMULATIVE TRAUMA DISORDER -

Description of mechanism of injury

Not a diagnosis

It is a class of Musculoskeletal disorders in which chronic discomfort, pain & functional impairment may develop over period of time as a result of frequent, sustained & repetitive movements

Associated with rise in automation & specialization in work

Faster work rates & redesign of jobs require a worker to do a single task or a very limited number of tasks tens of thousands of time everyday

Who are affected?

Occupations requiring repetitive & continuous use of their hands

Computer keyboarding, repetitive assembly line work, repetitive crimping as in processing industries

Clerical workers

Athletes

Musicians

Dominant hand presents earlier

Symptoms are confusing

Attempts to define specific diagnosis are necessary

Because = each disorder has a different cause, treatment & prognosis

Does not have single initiating event

Symptoms initially – subjective, non specific to Musculoskeletal system

Initially ache present at work but disappears at rest

If individual avoids repetitive work or the relevant work conditions that aggravate or precipitate the conditions are appropriately altered, CTD will resolve

If exposure continues  symptoms progress  more defined to a specific disorder affecting a combination or a single component of the musculoskeletal system.

Neural compression, inflammation of muscle tendon unit, vascular alteration Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER

Cannot be viewed as circumscribed physical phenomenon alone

Have a sociological, psychological & political impacts the patient’s progress & outcome

Unproven etiologies, insidious onsets, few objective signs, variable symptoms

Issue of legitimacy of the conditions & question their work status

Impact of disorder on employers, unions, insurers, government agencies apart from individual & family

Medical payment & reimbursement problems  Financial hardship  Psychological stress  Depression from physical effects 

Threat to persona, career & daily rhythm of life

TYPES OF CTDs 1. Tendinitis/Tenosynovitis –

Lateral epicondylitis,

–

Extensors

–

DeQuervain’s tenosynovitis – intersection syndrome, Extensor indicis proprius, ECU

–

Flexors – FCR, FCU, Trigger digits

2. Nerve compression syndromes –

Carpal tunnel syndrome

–

Cubital tunnel syndrome

–

Cervical radiculopathy

–

TOS

–

Anterior interosseus syndrome Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER –

Posterior interosseus syndrome

–

Pronator teres syndrome

–

Guyon’s canal syndrome

3. Pain syndromes -

Mayofascial pain syndrome

Fibrositis

Fibromyalgia

RSD

4. Other -

Vibration white finger

Arthritis

2. Overuse Syndromes 3. Repetitive Strain Injuries 4. Cervical Brachial Disorders

COMPONENTS OF THE EVALUATION PROCESS History

Subjective

Objective

Health history form

Current symptoms ROM

Sensory Provocative tests

H/o employment injury Pain status

Strength

Semmes- Weinstein Test

ADL status

Volume

Vibrometry

Palpation for trigger points, Stress tests Nodules, swelling Analysis of posture Work simulation

WORK RELATED RISK FACTORS FOR CTD 

Repetition



Vibration



High Force



Prolonged Static Positioning



Awkward Joint Posture



Direct Pressure Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER CUMULATIVE TRAUMA

When Force Is Applied To Same Muscle Or Muscle Group  Rapid, Repetitive & Forceful Movements  Inflammatory Response In The Tendon, Muscle Or Nerve  Localized Muscle Fatigue  Ischemia & Metabolic Change That Impairs Muscle  Enzyme Function  Muscle Cramp  Susceptible To Micro Tears & Inflammatory Changes  Pain During Work  Not Relieved By Rest  Severe Cases Sleep Disturbed

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER

FUNCTIONAL GRADING OF CTDS GRADE I

Pain after activity Resolves quickly with rest No decrease in amount or speed of work Objective findings usually absent

GRADE II

Pain in one site while working Pain is consistent while working, but resolves when activity stops. Productivity may be mildly affected May have objective findings

GRADE III

Pain in one or more sites while working Pain persists after activity is stopped Productivity affected & multiple breaks may be necessary to continue working May affect other activities away from work May have weakness, loss of control & dexterity, tingling, numbness, and/or other objective findings May have latent or active trigger points

GRADE IV

All common uses of hand/UE cause pain, which is present 50 â&#x20AC;&#x201C; 75% of the time May be unable to work or works in limited capacity May have weakness, loss of control & dexterity, tingling, numbness, trigger pints, and/or other objective findings

GRADE V

Loss of capacity to use hand because of chronic, unrelenting pain Usually unable to work Symptoms may persist indefinitely

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER TREATMENT PHASE I TREATMENT = SYMPTOM CONTROL = STRENGTHENING 

Acute phase -

Decreasing inflammation through dynamic rest

Splints – for immobilization, alone may relieve symptoms

Removed 3 times a day for stretching of affected musculature, maintain or increase muscle length, avoid joint stiffness.

E.g. extensor group in lateral epicondylitis

Painful activities avoided during dynamic rest phase

Massage = for edema control & reduction of pain

Vibration contraindicated – contribute to inflammatory problems

Combined with cortisone injections to reduce inflammation

Icing, contrast baths, ultrasound phonophoresis, Interferential, high voltage electrical stimulation  reduce pain & decrease inflammation



NSAIDS

Exercise phase (sub acute phase) -

Warming up of muscles by slow stretching

Controlled progressive exercises

PRE = Resistance at the end of range

Tennis elbow armband = over extensor muscle belly  limit full excursion of the muscle during active use of the arm

Resistance should be increased slowly = should not cause an increase in pain

Stretching three times a day = before activity = indefinite time

Proper body mechanics = long term control of inflammatory problems

Aware of what triggers symptoms

Learn early intervention if symptoms reappear

Icing, stretching, modified activities, correct body mechanics

Massage = aid in pain reduction, maintain tissue mobility

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER -

KEY = patient learn self management techniques & take an active role in their treatment

Evaluation of job site, tools used, hand position during work activities

Modification of the equipment used

Strengthening of the dominant muscle groups & their antagonists

PHASE II TREATMENT = CONDITIONING (final phase) –

Return to work

–

Work conditioning or work hardening

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BTE work simulator

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Tool and/or work site modifications = help prevent reinjury

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Ergonomic modifications = different type of handle on a tool, change in height work table

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Work out with patient and employer

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Return to work instructions should be well coordinated & communicated to both supervisor & patient to prevent misunderstanding

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Light duty

–

Monitor periodically

TENDINITIS -

Occupational illness

Because of overuse

Some use CTD, RSI, Overuse syndrome and tendinitis synonymously

Other “tendinitis differ from overuse syndrome”

Tendinitis = inflammation of tendons & muscle tendon attachment, spontaneous in onset, after a single traumatic event, sometimes after repetitive use, pain well localized with swelling of the tendon sheaths, local tenderness & induaration, weakness secondary to pain

CTD = due to micro trauma that results from the cumulative effect of repetitive stress on tissues, occur after long hours of repetitive use in unusual positions, pain diffuse &

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER poorly localized, swelling in the muscle bellies & musculotendinous junction or muscle origin, weakness is general & tenderness is subtle & diffuse -

Tendons are vulnerable – as they are relatively avascular

Repetitive micro trauma  cell damage with acute inflammation  chronic

Vicious cycle of pain, instability & dysfunction

Biomechanical defects  weakness, inflexibility, scar tissue

Early treatment of an acute traumatic case typically has a better prognosis than after the injury has become chronic.

EVALUATION -

An overaggressive evaluation that provokes pain can set the treatment timetable back significantly & undermines the trust of & rapport with the patient.

Cervical screening  to look for proximal causes of distal symptoms

Compare both extremities

Assess pain – local, diffuse

Swelling

Sensory changes

Loss of function

Pain = with AROM, with resistance, with passive stretch of the involved structures

Compare subjective & objective findings

Symptoms often elusive, occur dynamically or intermittently

Angry or hostile  depressed over their loss of function

Identify activity causing pain

Ergonomic related activity analysis

Observe actual activity or simulated

Identify ergonomic risk factors = forceful, rapid, repetitive movements

Repetitive movement = if performed > once every 30 seconds or for > half the total work time

Additional risk factors = history of soft tissue problems, pressure & shear forces, stress & muscle tension, hyper mobility

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER TREATMENT -

Treat acute phase with rest, ice, compression & elevation of the involved structures

Anti inflammatory physical agent modalities

Splinting individualized = beneficial, least problematic at night

Immobilization  disuse

Soft supports are helpful

Try to avoid pain

After inflammation subsides, upgrade treatment to restore normal function through gradual mobilization balanced with rest

Tendon gliding exercises in pain free range appropriate to particular structures involved

Isometric exercises with gentle contractions  isotonic low load, high repetition strengthening in short arcs of motion

Increase the arc of motion & modify proximal positions to be challenging if appropriate for work simulation

Gentle flexibility exercises in pain free range

Difficult to learn = slow & pain free passive stretch

Aerobic exercises & proximal conditioning

Prevent reinjury through education

Simulation & biofeedback promote biomechanically efficient UE use

Teach the patient to avoid reaching & gripping with an extended elbow, flexed or deviated wrist.

First solve easily recognizable issues = obviously poor posture, trunk twisting with reaching & lifting

Instruct in pacing to avoid fatigue that leads to reinflammation

Unsupported UE movement, nonsymmetrical UE use, nonfrontal trunk or UE alignment, unilateral UE work = taxing

Distal symptoms may recover well by focusing treatment on posture, conditioning & proximal strengthening

Use hand-held tools with ergonomic design Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER -

Ergonomic adjustments = lift bilaterally with proper biomechanics, use of a telephone headset instead of laterally flexing the neck & elevating the receiver

Tendinitis and Tenosynovitis CYCLE Normal Activity  Overuse  Micro trauma  Swelling  Pain  Limitation in movement  Rest  Disuse  Weakness  Normal activity -

Combination of

Localized pain,

Swelling,

Pain with resisted motion of the affected musculotendinis unit

Limitation in motion

Weakness

Crepitation of the tendons Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER -

Symptoms reproduced with activity or wok simulation

Isometric grip strength may be normal

Wrist, forearm strength decreased, out of balance

Dynamic grip strength = more limited because tendon gliding may increase inflammation & pain. -

Muscle imbalance  Positioning & substitution patterns  Worsening or spreading of symptoms

Lateral epicondylitis -

Tennis elbow

Involves extrinsic extensors at their origin

ECRB is most commonly involved

Pain at the Lateral epicondyle & extensor wad (proximal portion of the extensor muscles)

Differential diagnosis = radial tunnel syndrome = tenderness more distally over the radial tuberosity = middle finger test positive

Middle finger test positive = pain secondary to resisting the MF proximal phalanx while the patient maintains elbow extension, wrist neutral, MP extension

Percussion test = percussion distally over the superficial radial nerve  elicits Paresthesias

Exercises = proximal conditioning, scapular stabilizing

Build up handles

Splint = support wrist in extension, night, neutral to 30 degrees

Counterforce strap = a strap placed over the extensor wad to prevent full muscle contraction & to reduce load on the tendon during the day with activity

Avoid applying the counterforce strap too tightly; this can cause radial tunnel syndrome

De Quervain’s Disease -

Tendinitis involving APL, EPB tendons at the first dorsal compartment Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER -

Most common

Positive Frinkelstein’s test = exquisite pain with passive wrist deviation while flexing the thumb

Golfers, knitters, racquet sports players, mail sorters, filing clerks

Thumb posture in sustained hyper abduction may be provoking]

Differential diagnosis = carpometacarpal arthritis, scaphoid fracture, intersection syndrome, FCR tendinitis

Avoid wrist deviation, while pinching

Built up handles

Splint – forearm based thumb spica, leaving IP free

Watch for irritation from the radial splint edge along the first dorsal compartment

Medial epicondylitis -

Golfer’s elbow

Involves extrinsic flexors at their origin, FCR most common

Pain at medial epicondyle & flexor wad (the proximal portion of the flexor muscles),

Pain with resisted wrist flexion & pronation

Exercise to promote proximal conditioning

Avoid end ranges with forceful activity

Provide build up handles

Splint = maintain the wrist in neutral

Counterforce strap over flexor wad

Extensor Carpi Ulnaris Tendinitis -

Pain & swelling distal to the ulnar head

Associated with repetitive ulnar deviation motions

Subluxation of ECU tendon elicits a painful snap with forearm supination & wrist UD

Differential diagnosis = instability of distal radio-ulnar joint, ulno-carpal abutment or tear of the triangular fibro cartilage complex (TFCC)

Avoid UD with activities

Splint = forearm based gutter or wrist cock up splint

Flexor Carpi Radialis Tendinitis -

Pain over FCR tendon just proximal to the wrist flexor creases Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER -

Differential diagnosis = volar ganglion, arthr itis of scapho trapezio trapezoid joint

Splinting = wrist cock up in neutral or position of comfort

Flexor Carpi Ulnaris tendinitis -

More common than FCR tendinitis

Pain along volar ulnar side of the wrist

Inflammation where FCU inserts at the pisiform

Differential diagnosis = pisiform fracture, pisotriquitral arthritis, TFCC injury

Avoid wrist flexion with UD

Splint = forearm based ulnar gutter

Extensor Pollicis Longus tendinitis -

Drummer boy palsy

Associated with activities requiring repetitive use of thumb & wrist as seen in drummers

Pain & swelling at Lister’s tubercle (a dorsal prominence at the distal radius around which EPL passes)

Less common

If untreated tendon rupture

Rupture of EPL in RA or Colles’ fracture

Identify & eliminate provocative activities

Enlarge the girth of utensils

Splint = forearm based thumb spica that includes the IP

Intersection syndrome -

Pain, swelling & crepitus of the APL & EPB muscle bellies approximately 4cm proximal to the wrist, where they intersect with the wrist extensor tendons (ECRB, ECRL)

Associated with repetitive wrist motion = weight lifters, rowers, canoers

Differential diagnosis = de Quervain’s disease, both can occur concomitantly

Avoid painful or resisted wrist extension & forceful grip

Splinting = same as de Quervain’s, forearm based thumb spica, leaving IP free

Flexor tenosynovitis -

Trigger finger Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER -

Stenosing tenosynovitis of the digital flexor

Usual cause = stenosis at the A-1 pulley, which is part of the fibro-osseous tunnel that prevents bow-stringing of the digital flexors

Tenderness over A-1 pulley

Pain with resisted grip, painful catching or locking of the finger in composite flexion

Origin can be inflammatory or not

Strong association with diabetes & RA

Local anesthetic & steroid injected into the flexor sheath

Injection can be repeated a few times

Splinting MP in neutral to prevent composite digital flexion (preventing triggering) while promoting tendon gliding

Place & hold fisting that avoids triggering

Build up handles

Padded gloves

Pacing strategies

Instruct to avoid triggering ď&#x201A;Ž reinflames the tissue

Surgically release the A-1 pulley

NERVE COMPRESSION SYNDROMES -

Carpal tunnel syndrome

Symptoms â&#x20AC;&#x201C; night pain, severe enough to waken the patient, tingling in the thumb & long fingers, wasting of thenar muscles caused by pressure on motor branch (advanced)

Early recognition by nerve evaluation

Pressure on the median nerve = as it travels beneath the TCL at the volar surface of the wrist

Associated with increase pressure in the carpal canal because of 1. Trauma 2. Edema 3. Retention Of Fluids As A Result Of Pregnancy 4. Flexor Tenosynovitis Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER 5. Repetitive Wrist Motion 6. Static Loading Of The Wrist -

Conservative treatment = attempted first

Splinting wrist in no more than 20 degree extension,

Custom fabricated semi flexible splint, neoprene splint rather than completely rigid splint = to provide support, allowing small amount of flexion & extension for greater functional use

Contrast baths to reduce EDEMA

Edema â&#x20AC;&#x201C; for sitting, many find increased comfort by resting the forearms & hands on a pillow placed on a lap

How to position their hands & arms when walking

Wearing isotoner gloves

Activity analysis

Ultrasound phonophoresis = to reduce inflammation

Icing technique

Specific strengthening exercises of the wrist, fingers & thumb = when pain & inflammation have been controlled

ACTIVE & PASSIVE ROM -

Assess the trunk & limb ROM

Alteration in response to pain, lack of movement in one location

Deficient movement in the spine & the extremities

Neck, shoulder affectation for wrist & hand CTD = prolonged postural alteration

Discourage simultaneous movement or positioning in the same direction across both the joints in two-joint muscles in the symptomatic region

Stabilize the wrist in neutral position to reduce tension of the long flexors & extensors

During wrist motion digits are held in relaxed posture

Writing = learns to use this pattern by using 25 â&#x20AC;&#x201C; 30 degree inclined board to write on with an enlarged pen

Taught to adjust the height of an object to be worked on, wrist is positioned in neutral while the hand is fisted or is pinching Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER

MAYOFASCIAL PAIN & FIBROSITIS -

Pain elicited by activation of trigger points within the muscles & resulting in pain referred to a distal area

Poor posture & positioning of the body out of normal alignment

Careful examination of the patient & his/ her normal daily activities

Observe the patient performing the activity rather than rely on a verbal description

Mayofascial pain should be considered = where direct treatment of the painful area does not relieve the pain

Meticulous evaluation of trigger points

Mapping of trigger points &referral areas documented

Trigger points should be treated NOT referral area.

Ice, ultrasound phonophoresis

Friction massage, TENS

Activity analysis = to relieve the stresses on the affected tissues

Altered or limited ability to apply pressure, lift, carry & manipulate components of

ADL

usual ADL tasks -

Detailed inquiry = to determine the ability to eat, dress, perform personal hygiene, use transportation, maintain at home, write, use of telephone/ mobile phone, keyboard on the computer/mobile phone, and do leisure activities

Goal = restoration of safe ADL performance

Methods of joint protection & energy conservation to avoid precipitating & aggravating postures & movements

Significant functional impairment, fine motor coordination tasks

Adaptive equipment

Creative problem solve = innovative solutions to manage fasteners, change purses, dental floss, pen or pencil

B/o weakness = lifting capacity limited to 3 or 5 lb ď&#x201A;Ž backpack or waist pack that relies on the support of larger muscles of shoulder & trunk to carry groceries, laundry, books, musical instruments Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER -

Lower endurance = affects sustained static patterns, difficulty holding onto newspaper for more than a few minutes  reading the paper on a table

Spontaneously dropping things  use paper or plastic products in kitchen, to work over a surface to minimize spillage, monitor hands visually during tasks

Lower tolerance to vibration = limit the amount of time that person can handle the steering wheel in the car  more frequent balancing of tires

Vibration of hair dryers = irritating to the hands  mount on the wall

Improved endurance  ADL methods upgraded  but adhere to the biomechanical principles for joint protection

WORK & LEISURE -

People are affected in the beginning or the first half of their career cycle

Ability to perform physically active sports & ability to participate in travel with family & friends hindered

Sedentary activities like reading & playing cards – difficult to do

Unable to hold book for long

Shuffling & holding cards not possible without adaptations

Vital to identify ways to assist to either continue with important recreational activities

Help select activities which are relaxing & meaningful

Swimming, yoga, ballet

Pain profile – to document localized & referred pain pattern & duration & intensity

Some describe onset from a specific activity/ movement

Pain reaction delayed following a precipitating factor

Advanced symptoms = always in pain, but intensity varies, not related to

PAIN

activity/position -

Local heat through whirlpool, fluidotherapy, paraffin, heat packs

Deep heat – acoustic vibration (ultrasound), electrical stimulation such as galvanic, iontophoresis, TENS

Home programme – cooling with ice packs, local moist heat applications, TENS Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER

SCAR MANAGEMENT Progression of inflammatory process & recurrent micro-trauma  Scarring & shortening of the muscle-tendon tissue  Prevent inflamed & painful muscle-tendon unit from becoming fibrotic  Deep massage & ultrasound to stimulate fibroblast activity on the inflamed tissue  Supportive static splints – prevent inflamed regions from stiffening in shortened position

INTERVENTION MODELS 

Vocational model



Case management



Industrial model

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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