greetings from university of southampton

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

5. Pathology

6. 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

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

17. Tennis Elbow Lateral Tendinitis of Common Extensor Origin

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) Mechanical inhibition of force transference to the ECRB origin during activities that load the ECRB tendon distally Mechanical inhibition of force transference to the ECRB origin during activities that load the ECRB tendon distally

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

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

30. De Quervain�s disease

31. De Quervain�s Disease

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

33. 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. Intralesional corticosteroids injection Ultrasound treatment Friction massage

37. Surgical intervention

38. Highlight pick up large object by using 1st web forceful pinch action use of scissors, cutter open bottle grocery shopping holding pen De Quervain�s: Patient education

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. CTS: Surgical Intervention Open release + Camitz transfer

46. 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. 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

51. 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

52. Ergonomic Measures to avoid CTD: Education Aim: Reduce exposure to risk factors Method Proper lifting posture Recommendation of � max lifting weight Heavy work workers ~ 50% of maximum lifting capacity by lifting assessment

53. Ergonomic Considerations: Posture

54. Ergonomic considerations: use of hands

55. Ergonomically Designed Products

56. Ergonomically Designed Products

57. Ergonomically Designed Products

58. Continuous Education Review pathology & symptoms Reinforce application of techniques taught in daily lives Review warning sign Fatigue pain in forearm Early intervention symptoms reappear

61. References 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 biomechanical overload. Ergonomics,41, 1253-1260. Hunter, J. M. (1995). Rehabilitation of the hand: surgery and therapy. St. Louis: Mosby. Jacobs, K. (1999). Ergonomics for therapist. Boston, MA : Butterworth-Heinemann. Kroemer, K. H. E. (1989). Cumulative trauma disorders: Their recognition and ergonomics measures to avoid them. Applied Ergonomics, 20, 274-280.

62. References 7. Mayer, T.G., Gatchel, R.J. & Polatin, P.B. (2000) Occupational Musculoskeletal Disorder: Function, Outcome & Evidence. USE: Lippincott. 8. Nisrschl, R. P. (2000). Muscle and tendon trauma: tennis elbow tendinosis. In B.F., Morrey, the elbow and its disorders (pp.523-535). Philadelpha: W.B. Saunders. 9. Todd, S. E. & Angelo, J. M. (1997), The elbow in sport: Injury, treatment, and Rehabilitation. 10. Trombly. C.A (1995) Occupational Therapy for Physical Dysfunction 4th ed. p.409 � 419. USA . Williams & Wilkins. 11. Prdretti. L.W. & Early. M. B. (2001) Occupational Therapy Practice Skills For Physical Dysfunction 5th ed. P.858 � 860. USA. Mosby. 12. Stanley.B.G. & Tribuzi. S.M. (1992) Concepts in Hand Rehabilitation p. 429 � 431. USA. F. A. Davis.

63. Thank You