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Rehabilitation intervention for patients with upper extremity dysfunction: challenges of outcome evaluation.
Upper extremity (UE) dysfunction attributed to overuse is an increasingly prevalent problem managed with interdisciplinary rehabilitation. Outcome evaluation of these programs is limited by a number of factors. First, patients with UE dysfunction include a wide variety of pathophysiologic processes and diagnoses that are associated with multiple secondary impairments, disabilities, and handicaps that limit personal performance. Second, the particular experience of disablement and expectations each person brings to the rehabilitation process necessitates an individualized program with unique goals. Successful outcome measurement of the rehabilitation process must take into account the achievement of individual goals as well as objective scalar quantification of impairments, disabilities, and handicaps that are comparable between groups. Understanding of the relationships between UE impairments and given functional outcomes will come from controlled, dosed treatment studies in "pure" diagnostic patient groups. Outcomes research applied to UE rehabilitation as it is currently practiced should include individually devised patient assessments of accomplishment and satisfaction in addition to long-term quantitative reassessment of the person under all domains of disablement and work performance.
Upper limb repetitive strain injuries in Manitoba.
A review of workers' compensation board (WCB) claims in Manitoba, Canada identified an estimated 382 upper limb repetitive strain injury (RSI) claims or 9.3% of all upper limb WCB claims accepted in 1991. Tendonitis and carpal tunnel syndrome (CTS) were the most frequent diagnoses (27.5% and 19.3%, respectively). Rates of RSI were not significantly different by gender and age. RSI claimants had been experiencing symptoms for an average of 8 months prior to filing a compensation claim. While clerical occupations accounted for 13.6% of all upper limb RSI claims, the rates for RSIs in these occupations were low (0.67/1,000 workers), in contrast to occupations with the highest RSI rates: food, beverage, and related processing occupations (14.68/1,000 workers) and fabricating, assembling, and repairing of metal products (9.32/1,000). The highest risk industries were meat and poultry processing-related (23.48/1,000) and the manufacturing of airplanes (9.06/1,000). RSI claims were significantly more costly (+5,569 vs. +2,480, p < 0.0001) and required more time loss (71.4 vs. 33.6 d, p < 0.0001) than similar musculoskeletal non-RSI claims. Similarly, RSI claimants were less likely to return to the same job (67.3% vs. 81.0%, p < 0.0001) than non-RSI claimants. It was concluded that the cost and severity of RSI claims militate for intensified preventive measures.
Carpal tunnel syndrome: validation of an interview questionnaire on occupational exposure.
The objectives of this study were 1) to summarize in a clinically meaningful way information on occupational risk factors for carpal tunnel syndrome (CTS), and 2) to test a questionnaire on risk factors that could be used by physicians with their patients. For the two objectives, a systematic literature review was performed and synthetized graphically, and a questionnaire was developed and administered to 238 patients who underwent release surgery for CTS. Patients were classified in four groups according to the incidence rate of CTS surgery in their occupation. Answers to the questionnaire on exposure to risk factors for CTS were compared between these four groups with the hypothesis that the group with the highest incidence would report the highest exposure. The results showed that questioning workers on the amount of force required to perform tasks that are "especially demanding" for the wrists or hands is both useful clinically and valid to be used by the clinician to make a judgement on the occupational nature of CTS. Repetitiveness and segmental exposure to vibrations or to cold are potentially useful and will need further validation. There is no evidence at present that posture or motion of the wrists is potentially useful to describe occupational exposure when questioning patients with CTS.
Clinical evaluation and management of work-related carpal tunnel syndrome.
Carpal tunnel syndrome (CTS) is a clinical entity characterized by pain, paresthesias, and numbness in the distribution of the median nerve with weakness and atrophy of the thenar muscles in advanced cases. It is universally accepted that CTS is the clinical concomitant of compression of the median nerve as it passes through the carpal canal. It is reported to be the most common of the entrapment neuropathies. Increasing evidence suggests that occupational factors, including forceful use of the hands, repetitive use of the hands, and hand-arm vibration, are etiologic for CTS. When occurring as a result of occupational exposures, the term "work-related carpal tunnel syndrome" is applied. Clinical approaches to the diagnosis and treatment of work-related CTS are described in this paper. Particular attention is paid to the clinical features and pathophysiology of CTS, the epidemiology of work-related CTS, ascertainment of work-relatedness in the clinical setting, treatment including both work and non-work interventions, and control of occupational ergonomic risk factors that may contribute to the illness.
Pitcher's arm: an electrodiagnostic enigma.
Every major league baseball pitcher, most minor league pitchers, but only few amateur pitchers that we have studied have had reduced sensory nerve action potentials in the throwing arm. We present 6 clinical cases which demonstrate the spectrum of "pitcher's arm." These cases suggest that the phenomenon is a pathologic process, probably an example of a repetitive use syndrome affecting the brachial plexus. Although it does not appear to impact performance, it has clear implications for the interpretation of electrodiagnostic studies in symptomatic pitchers.
Job stress, upper extremity pain and functional limitations in symptomatic computer users.
BACKGROUND: Research suggests that exposure to occupational stressors are related to the presence and/or exacerbation of work-related upper extremity symptoms in office workers. Also worker's response to work demands and/or job stressors (i.e., workstyle) may exacerbate symptom severity and impact function. The present study examines the association among work demands, job stress and workstyle on pain and function. METHODS: 124 symptomatic female office workers completed a questionnaire measuring demographics, medical history, work demands, perception of the work environment, workstyle, pain intensity, functional impact, and time lost from work. RESULTS: Heightened job stress and the tendency to continue to work in a way that contributes to pain to ensure high quality (dimension of workstyle) were related to pain intensity at work and decreased function. These variables, in addition to hours worked per year, were related to increased pain experienced across the work week. The model tested did not predict the occurrence of lost time. CONCLUSIONS: The present findings provide support for the association between job stress, workstyle, upper extremity pain and function. While it is not possible to determine the exact direction of the observed relationships, these results are consistent with prior research indicating the potential significance of job stress and workstyle on symptom exacerbation and functional limitations. Implications for evaluation and intervention are discussed.
Interventions for preventing lower limb soft-tissue injuries in runners.
BACKGROUND: Overuse musculoskeletal injuries occur frequently in runners. Suggestions for prevention have focused on stretching exercises, modifying training schedules and the use of protective devices such as braces and insoles. To date, no systematic analysis of the literature on the effectiveness of these strategies in the prevention of overuse injuries has been published. OBJECTIVES: The objective of the review was to evaluate the evidence from randomised controlled trials on the prevention of lower limb soft-tissue running injuries. SEARCH STRATEGY: An electronic database search included The Cochrane Musculoskeletal Injuries Group specialised register (date of last search October 2000), The Cochrane Controlled Trials Register (The Cochrane Library, Issue 3, 1999), MEDLINE (from 1966), EMBASE (from 1980), SPORT Discus (1975-2000), HERACLES (1975-2000), ATLANTES (1980-1996), BIOSIS, CINAHL, SCISEARCH, Current Contents, Index To Theses and Dissertation Abstracts. Date of last search for these databses: May 2000. SELECTION CRITERIA: Any randomised or quasi-randomised trials evaluating interventions to prevent lower limb soft-tissue running injuries. DATA COLLECTION AND ANALYSIS: All trials fulfilling the selection criteria were assessed by two reviewers independently. Data were also extracted independently by the two reviewers using a pre-derived data extraction form. Exploratory analyses, including pooling of results from groups of trials of similar designs were undertaken, using a fixed effects model. Results were reported as relative risks (RR) with 95 per cent confidence intervals (95% CI). MAIN RESULTS: Twelve trials with 8,806 participants were included. In one trial, a single control group was matched to three different included intervention groups. The effectiveness of stretching exercises (5 trials, 1944 participants in the intervention groups, 3159 controls), and of insoles and footwear modification (5 trials, 903 participants in the intervention groups, 3006 controls) in the prevention of lower extremity soft tissue injuries associated with running is unknown. Reducing the distance, frequency and duration of running may be effective in the prevention of lower extremity soft tissue injuries associated with running (3 trials, 514 participants in intervention groups, 1663 controls). Wearing a knee brace with a patellar support ring may be effective in the prevention of running-associated anterior knee pain (1 trial, 27 participants in the intervention group, 33 controls). REVIEWER'S CONCLUSIONS: This review provides some evidence for the effectiveness of the modification of training schedules, but there is insufficient evidence to determine the effectiveness of stretching exercises for major lower limb muscle groups in reducing lower limb soft-tissue running injuries. More studies are required to confirm that knee braces may prevent knee pain, to clarify the role of stretching, and to quantify optimal training loads. Generalisability of the results may be limited by the intensive nature of military training (the context for most of the studies) and the inclusion of only small numbers of women.
Movement dysfunction following repetitive hand opening and closing: anatomical analysis in Owl monkeys.
Repetitive strain injuries are thought to result from biomechanical stress and tissue microtrauma. The purpose of this study was to investigate the presence of local inflammation, scarring or anatomical variations of the flexor tendons and the median and ulnar nerves in four Owl monkeys behaviorally trained at a repetitive motor or sensory task. Three monkeys were trained to repetitively open and close a handpiece. The two monkeys that used rapid, stereotypical hand squeezing developed a task-specific movement dysfunction (one in 5 weeks and one in 24 weeks). The third monkey used a variable shoulder-pulling strategy and did not develop movement problems. The fourth monkey served as a control subject for the repetitive motor movements, trained on a repetitive sensory task, and did not develop a task-specific movement dysfunction. On dissection and histologic staining, there were no signs of active inflammation in the median nerve, the ulnar nerve, or the flexor tendons in any of the monkeys. However, the monkey that developed movement problems after 5 weeks of repetitive hand squeezing had an anatomical restriction of the flexor profundus tendon on the fourth digit of the trained side and the third digit of the untrained side. Reorganization of the representation of the hand on the contralateral somatosensory cortex (area 3b) was noted in the two monkeys that developed motor control problems and in the monkey performing the repetitive sensory task. These findings suggest that repetitive, stereotypical motor behaviors can lead to motor control problems without local signs of tendon or nerve inflammation. Preexisting anatomical restrictions may modify the time course for the development of movement dysfunction under conditions of stressful repetition. This animal model may simulate clinical focal hand dystonia (or occupational hand cramps) which can develop in human subjects who perform prolonged, repetitive, stereotypical movements.
Test-retest reliability of the Upper Extremity Questionnaire among keyboard operators.
BACKGROUND: Questionnaires are often used in research among workers although few have been tested in the working population. The Upper Extremity Questionnaire is a self-administered questionnaire designed for epidemiological studies and tested among workers. This study assessed reliability of the instrument. METHODS: A two-part assessment was conducted among 138 keyboard operators as part of a large medical survey. Test-retest reliability was analyzed using the kappa statistic, paired t-test, and intraclass correlation coefficient (ICC). Logistic regression models were used to test the effect of demographic and work-related factors on reliability. RESULTS: The average respondent was a white woman, age 35 years, with some college education, in permanent employment with tenure of 1.4 years. Overall, reports of symptoms were stable from Round 1 to 2. Most kappa values for symptom reports were between 0.60 and 0.89. Kappa values for right and left hand diagrams were 0.57 and 0.28, respectively. Among psychosocial items, Perceived Stress and Job Dissatisfaction Scales were most reliable (ICC = 0.88); co-worker support was least reliable (ICC = 0.44). CONCLUSION: Reliability of items on the Upper Extremity Questionnaire were generally good to excellent. Reports of symptom severity and interference with work were less stable. Demographic and work-related factors were not statistically significant in modeling the variation in reliability. Repeated use of the questionnaire with similar results suggests findings are applicable to a larger working population.
Upper extremity pain and computer use among engineering graduate students.
BACKGROUND: The objective of this study was to investigate risk factors associated with persistent or recurrent upper extremity and neck pain among engineering graduate students. METHODS: A random sample of 206 Electrical Engineering and Computer Science (EECS) graduate students at a large public university completed an online questionnaire. RESULTS: Approximately 60% of respondents reported upper extremity or neck pain attributed to computer use and reported a mean pain severity score of 4.5 (+/-2.2; scale 0-10). In a final logistic regression model, female gender, years of computer use, and hours of computer use per week were significantly associated with pain. CONCLUSIONS: The high prevalence of upper extremity pain reported by graduate students suggests a public health need to identify interventions that will reduce symptom severity and prevent impairment.
Upper extremity symptoms in supermarket workers.
Upper extremity symptoms in supermarket workers, particularly those who performed checking using laser scanners, were evaluated using a questionnaire administered by trained interviewers to 124 supermarket workers. Summary indices of exposure (short-term and long-term) as well as indices of past personal illnesses and personal activities were employed. Outcome data were summarized by four composite symptom indices. Chi square and logistic regression analyses demonstrated that hours of checking work in the preceding 2 weeks and cumulative weighted years of work were associated with adverse upper extremity symptoms. Symptoms involved both the proximal and distal parts of the upper extremities.
Carpal tunnel syndrome among grocery store workers.
The California Department of Health Services evaluated carpal tunnel syndrome (CTS), a median nerve entrapment condition associated with forceful and repetitive wrist motion, among grocery store workers at a large California supermarket where a CTS cluster had been reported. Forceful and repetitive wrist motion was measured, in three exposure levels, through a job classification scheme based upon type of work tasks and average time per week spent performing these tasks. A medical questionnaire and measurements of median sensory nerve conduction were used to measure CTS. CTS prevalence was 23% based upon a sample of 56 participants drawn from a workforce of 69 employees. A relative risk of 8.3 (95% confidence interval 2.6-26.4) for a history of CTS-like symptoms between the high and low exposure level groups held up after adjustment for the potential confounders of age, sex, alcohol consumption, and high-risk medical history. It was concluded that the basic principles of good ergonomic design should be used to prevent or diminish the risk of musculoskeletal injury in the workplace.
Hypothesis relating cumulative trauma to the median nerve with sub-clinical nerve conduction deficits.
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Prevalence and work-relatedness of self-reported carpal tunnel syndrome among U.S. workers: analysis of the Occupational Health Supplement data of 1988 National Health Interview Survey.
To estimate the prevalence and work-relatedness of self-reported carpal tunnel syndrome (CTS) among U.S. workers, data from the Occupational Health Supplement of 1988 National Health Interview Survey (NHIS) were analyzed. Among 127 million "recent" workers" who worked during the 12 months prior to the survey, 1.47% (95% CI: 1.30; 1.65), or 1.87 million self-reported CTS, and 0.53% (95% CI: 0.42; 0.65), or 675,000, stated that their prolonged hand discomfort was called CTS by a medical person. Occupations with the highest prevalence of self-reported CTS were mail service, health care, construction, and assembly and fabrication. Industries with the highest prevalence were food products, repair services, transportation, and construction. The risk factor most strongly associated with medically called CTS was exposure to repetitive bending/twisting of the hands/wrists at work (OR = 5.2), followed by race (OR = 4.2; whites higher than nonwhites), gender (OR = 2.2; females higher than males), use of vibrating hand tools (OR = 1.8), and age (OR = 1.03; risk increasing per year). This result is consistent with previous reports in that repeated bending/twisting of the hands and wrists during manual work is etiologically related to occupational carpal tunnel syndrome.
Surveillance and prevention of work-related carpal tunnel syndrome: an application of the Sentinel Events Notification System for Occupational Risks.
In response to limitations in state-based, occupational disease surveillance, the California Department of Health Services developed a model for provider- and case-based surveillance of work-related carpal tunnel syndrome. The objectives were to enhance case reporting, identify risk factors and high-risk work sites, and link preventive interventions to work sites and the broader community. Using elements from surveillance of communicable diseases and sentinel health events, a model was integrated into the pre-existing reporting system in one California county. Between 1989 and 1991, 54 Santa Clara County health care providers reported 382 suspected cases, of which 365 from 195 work sites met reporting guidelines. Risk factors were profiled from interviews of 135 prioritized cases and 38 employers. Of 24 work sites prioritized for a free, voluntary, nonenforcement inspection, 18 refused and 6 completed an on-site visit. Sentinel Event Notification System for Occupational Risks (SENSOR) captured many cases not reported to the pre-existing reporting system. Case interviews indicated a profile of symptoms and signs, treatment, and exposure to uncontrolled occupational risk factors, including a lack of training on ergonomics hazards. Employer health insurance, rather than workers' compensation, was the apparent source of payment for most medical bills. Employers lacked knowledge and motivation to reduce ergonomic risks. Governmentally mandated occupational ergonomics standards are urgently needed.
Metacarpophalangeal arthropathy associated with manual labor (Missouri metacarpal syndrome). Clinical radiographic, and pathologic characteristics of an unusual degeneration process.
We describe 7 manual laborers with painful, palpably enlarged metacarpophalangeal joints. Characteristic radiographic changes were joint space loss, prominent osteophytes, and cystic metacarpal heads most prominent in the second and third metacarpophalangeal joints. In 3 of 4 patients, joint biopsy specimens showed subsynovial fibrosis and villous hyperplasia. All 7 patients had similar backgrounds of heavy work demanding sustained gripping motions of both hands, for periods that exceeded 30 years. We designated their condition metacarpophalangeal arthropathy associated with manual labor.
Mechanical injury and psychosocial factors in the work place predict the onset of widespread body pain: a two-year prospective study among cohorts of newly employed workers.
OBJECTIVE: Mechanical injury has been postulated as a risk factor for widespread pain, although to date, the evidence is weak. The aim of this study was to determine whether repeated exposure to mechanical trauma in the work place predicts the onset of widespread pain and to determine the relative contribution of mechanical trauma compared with psychosocial factors. METHODS: In this prospective cohort study of 1,081 newly employed subjects in 12 diverse occupational settings, we collected detailed information on mechanical exposure, posture, physical environment, and psychosocial risk factors in the work place. Study questionnaires were completed at baseline and at 12 and 24 months. Individuals free of widespread pain at baseline and 12 months were eligible for followup. Generalized estimating equations were used to determine which factors predicted the new onset of widespread pain. RESULTS: Of the 1,081 baseline respondents, 896 were free of widespread pain and were eligible for further study. Of these 896 subjects, 708 and 520 responded at 12 months and 24 months, respectively. The rates of new-onset widespread pain were 15% at 12 months and 12% at 24 months. Several work place mechanical and posture exposures predicted the new onset of widespread pain: lifting >15 lbs with 1 hand, lifting >24 lbs with 2 hands, pulling >56 lbs, prolonged squatting, and prolonged working with hands at or above shoulder level. Of the psychosocial exposures, those who reported low job satisfaction, low social support, and monotonous work had an increased risk of new-onset widespread pain. In multivariate analysis, monotonous work and low social support were found to be the strongest independent predictors of symptom onset. CONCLUSION: Our findings demonstrate that the prevalence of new-onset widespread pain was high, but among this young, newly employed work force, both physical and psychosocial factors played an important role.