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Greetings from University of Southampton

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).

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Greetings from University of Southampton

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  1. Greetings from University of Southampton

  2. 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.

  3. 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

  4. 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.

  5. Physiologically Tears of ECRB Adaptive change in tissue Thickening of tendon sheath Tendon deformation Overuse Mechanically Permanent pathology Pathology

  6. Repetitive Motion Force Exertion Microtears Relaxation  Tension  Pull on tendon Compress joint Tissue ischemia  Removal rate  Wear & Tear  Repair ability Further Tear Inflammation Pathology -- Mechanism

  7. Risk Factors • Force • Repetition • Posture • Duration • No rest • Personal factor: • anatomical build-up, working habit(work or household)

  8. Changes in Soft Tissue • Circulation : ischemia • Mechanical deformation • Tiny tear & micro-trauma • Inflammation & scar formation • Nerve compression

  9. Common Disorders • Tendon : Tendinitis ,Tenosynovitis, etc. • Nerve disorder : entrapment, compression, etc. • Neurovascular disorder : Thoracic Outlet Syndrome

  10. 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

  11. 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

  12. 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

  13. 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)

  14. Work Ergonomics • Job analysis • Risk factors identification • Work habit and layout modification • health concept of people

  15. 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

  16. Tendinitis • Tendinitis is a form of tendon inflammation that occurs when a muscle/tendon unit is repeatedly tensed. • Tendon becomes thickened, bumpy and irregular

  17. Cumulative trauma disorder Tennis Elbow • Lateral Tendinitis of Common Extensor Origin Characteristics of develop: • Multifactorial • Long time development (Grieco, 1998)

  18. 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

  19. 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

  20. Tennis Elbow : Management • Tennis Elbow Band • Tubigrip • Local injection • Heat/cold • Stretching Exercise • Strengthening Exercise

  21. 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

  22. 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)

  23. 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 & long- lasting • Overall relief & improved function

  24. Tennis Elbow : Patient education Highlight • Lifting and carrying habit • mopping floor • cleansing window • twisting towel • holding cooking pan • washing clothes

  25. 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

  26. Golfer’s Elbow

  27. Golfer’s Elbow: Assessment • Resting pain • Local tenderness: medial epicondyle, flexor muscle belly • Stress test: wrist flexion, pronation • Power grip • ADL

  28. Golfer’s elbow: Management • Golfer’s elbow band • Tubigrip • Stretching ex. • Strengthening ex. • Patient education • Work ergonomic advice

  29. 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

  30. De Quervain’s disease Abductor pollicis longus Extensor pollicis brevis

  31. De Quervain’s Disease

  32. De Quervain’s disease • Stenosing tenosynovitis • Abductor pollicis longus and extensor pollicis brevis

  33. Sharp pain De Quervain’s disease: Assessment • Resting Pain • Local Tenderness • Stress Test: Extension(EPB), Abduction(APL) • Finkelstein Test • Power grip

  34. De Quervain’s disease: Complication • Osteoarthritis of 1st CMC jt. • Tendinitis of wrist extensors • ganglia • radial sensory nerve entrapment (burning pain)

  35. 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.

  36. De Quervain’s disease: Management • Intralesional corticosteroids injection • Ultrasound treatment • Friction massage

  37. De Quervain’s disease: Management . Extensor carpi radialis longus and brevis tendons . Extensor pollicis longus tendon Extensor pollicis brevis tendon Abductor pollicis longus tendon Sensory branch of the radial nerve . • Surgical intervention

  38. 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

  39. Carpal Tunnel Syndrome

  40. 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

  41. CTS: Assessment • Night pain/numbness • Paresthesias • Stretch Test • Thenar atrophy • Tinel sign • Phalen’s test • Wrist ROM • Moving 2pd • Power and pinch • ADL

  42. CTS: Management • Splintage : night & day splint • Patient education: Ergonomic advice • Local injection • Surgical intervention: open release, endoscopic release.

  43. CTS: Splintage program • Night cock-up splint: < flexion 20° -- neutral -- < extension 20 ° • Day working splint

  44. 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

  45. . . Motor branch of the median nerve Palmar fascia Transferred palmar fascia Opening of the carpal tunnel Palmar branch of the median nerve Palmaris longus tendon . CTS: Surgical Intervention • Open release + Camitz transfer

  46. Sensory branch Transverse carpal lig. Motor branch Hook of hamate Guyon’s canal Pisiform bone Tubercle of scaphoid Ulnar nerve Median nerve Ulnar artery Palmar carpal lig. Volar carpal ligament (covering the ulnar artery and nerve) Flexor carpi radialis 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

  47. Cubital Tunnel Syndrome

  48. Incision Pseudoneuroma of the ulnar nerve Constriction band (Osborne) 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

  49. Cubital Tunnel Syndrome: Management • Work modification • Elbow padding • Surgical intervention

  50. 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

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