Management of upper extremity cumulative trauma disorders.

1. Elements critical to a successful medical management program include cumulative trauma disorder (CTD) surveillance, conditioning and rehabilitation programs, and familiarity with OSHA recordkeeping requirements, in addition to recognition, evaluation, and treatment. 2. Occupational health care providers (HCPs) can identify high risk departments, production lines, or jobs through the passive and/or active surveillance systems. 3. The HCP should perform a CTD evaluation of employees assigned to jobs with known ergonomic hazards or areas found to have CTD problems by the surveillance system. These evaluations should consist of a medical and occupational history, and a physical examination of the upper extremities. 4. The treatment algorithm emphasizes that a) symptomatic employees need follow up to determine the effectiveness of the prescribed treatments, b) employees with severe symptoms, positive physical findings, or disorders resistant to treatment need to be referred to a physician for further evaluation, and c) conservative therapy deserves an adequate trial before surgical intervention is contemplated.     

An investigation of symptom-specific muscle hyperreactivity in upper extremity cumulative trauma disorder.

OBJECTIVE: The study examined symptom-specific muscle hyperreactivity in patients with chronic pain with upper limb cumulative trauma disorder (CTD). DESIGN: Four tasks were presented in counterbalanced order and included neutral, general stressor, personal stressor, and pain stressor tasks. Ratings of stressfulness and recordings of skin conductance level confirmed the effectiveness of the experimental manipulations in inducing stress experiences for all subject groups. SETTING: The study was conducted in a university research center. PATIENTS: Thirty patients with CTD were matched as closely as possible for age and gender to control groups of chronic low back pain, arthritis, and pain-free subjects. OUTCOME MEASURES: Surface electromyograph recordings were taken from the frontalis, forearm flexors, trapezius, and lower back during baseline and tasks. RESULTS: The study found no evidence of greater muscle tension increases or extended duration of return to baseline for the CTD or low back pain patients at any of the muscle sites for any of the tasks in comparison to control groups. CONCLUSIONS: The results indicate that symptom-specific psychophysiological responses may be limited to certain subgroups rather than being characteristic of chronic musculoskeletal pain patients in general.     

Work-related upper extremity musculoskeletal disorders

Upper extremity musculoskeletal disorders such as DeQuervain's tendonitis, carpal tunnel syndrome, and rotator cuff tendonitis have become increasingly common among working people in the United States. Extensive epidemiological investigation indicates that the adverse ergonomic exposures of force, repetition, vibration and certain postures are risk factors for development of many of these disorders. Assessment of patients with possible work-related upper limb disorders requires eliciting information about the illness, performing an examination about the illness, and obtaining information about adverse ergonomic exposures on and off from work. Treatment can only be successful when exposure to adverse ergonomic risk factors is reduced or eliminated.     

Biological pathways between occupational stress and work-related musculoskeletal disorders of the neck and upper extremity

Abstract

Stress in the workplace is often linked with cardiovascular disease, hypertension, depression, and low job satisfaction. There is also evidence of an association between occupational stress and musculoskeletal disorders. However, evidence of a direct causal relationship remains elusive. This paper reviews the evidence for a plausible biological pathway between psychosocial stressors in the workplace and musculoskeletal disorders, particularly of the neck and upper extremity; it discusses how job stress can affect blood pressure, hormone levels and the immune system. However, by far the strongest evidence has been obtained through recording muscle electrical activity during low load and stressful tasks such as computer work. The evidence suggests an increase in muscle tension due to the need for postural stabilisation and high visual demands while using a computer keyboard or mouse. This increase occurs during task performance and during rest periods. A potential pathway between these various factors is outlined.     

Case management services for work related upper extremity disorders. Integrating workplace accommodation and problem solving.

A case manager's ability to obtain worksite accommodations and engage workers in active problem solving may improve health and return to work outcomes for clients with work related upper extremity disorders (WRUEDs). This study examines the feasibility of a 2 day training seminar to help nurse case managers identify ergonomic risk factors, provide accommodation, and conduct problem solving skills training with workers' compensation claimants recovering from WRUEDs. Eight procedural steps to this case management approach were identified, translated into a training workshop format, and conveyed to 65 randomly selected case managers. Results indicate moderate to high self ratings of confidence to perform ergonomic assessments (mean = 7.5 of 10) and to provide problem solving skills training (mean = 7.2 of 10) after the seminar. This training format was suitable to experienced case managers and generated a moderate to high level of confidence to use this case management approach.     

Evaluation of extremity trauma with sonography.

OBJECTIVE: To report on the use of bedside sonography in the diagnosis and treatment of penetrating extremity trauma. METHODS: Sonography was performed in the emergency department of a level 1 trauma center with both curved and linear array transducers. RESULTS: In both cases, foreign bodies and fractures resulting from gunshot wounds to the extremities were found. In addition, intra-abdominal and thoracic injuries were evaluated for using sonography. CONCLUSIONS: The increasing mobility and portability of sonography has led to its increasing use at the patient' bedside to diagnose a variety of conditions. It provides potential immediate diagnosis and has the flexibility for evaluating a multitude of injuries normally requiring several different imaging technologies. In circumstances in which conventional radiography is unavailable, such as at trauma scenes, mass casualty situations, or at the bedside with unstable patients, sonography can provide unique and essential information about these patients.     

The nurse as a survivor: delayed post-traumatic stress reaction and cumulative trauma in nursing

As opposed to studies on the immediate psychological impact of traumatic nursing experiences, little attention has been directed to the persistence of certain long-standing hidden symptoms of trauma in some nurses. Since psychological reactions to trauma are claimed to be similar, irrespective of the source of trauma, it is postulated that findings from recent studies on delayed post-traumatic stress reaction in Vietnam veterans, victims of natural disaster, and survivors of the holocaust, delineate symptoms which are also found in stress-prone nurses utilizing maladaptive coping strategies in response to hospital-related traumatic episodes. While some observations are conjectural and speculative, an integrated review is presented of areas of research hitherto unrelated, which serves to deepen our understanding of trauma and its impact upon the mental health of nurses.     

Perceived job stress, job satisfaction, and psychological symptoms in critical care nursing

This study tested the relationships among perceived job stress, job satisfaction, and psychological symptoms of critical care nurses. A self-administered questionnaire was sent to a sample of 180 critical care nurses from eight hospitals. The results supported the hypotheses that higher levels of perceived job stress are related to lower levels of job satisfaction (r = -.24, p = .001) and to higher levels of psychological symptoms (r = .33, p = .000). These effects remained even when years of experience in nursing and shift were controlled. Item analysis, however, showed that four of the five top-ranking stressors were not related to the outcome measures. A distinction between positive and negative stressors is proposed to explain the pattern of results.     

Interscalene blocks for chronic upper extremity pain.

A study of 25 patients was carried out to determine the efficacy of interscalene block (ISB) for the treatment of chronic upper extremity pain. An RSD score was used to categorize these patients. Seventeen of the 25 patients had less pain after ISB, and 14 also had increased range of motion of the affected limb. Patients with reflex sympathetic dystrophy (RSD)/causalgia, as well as other chronic pain conditions, improved. ISB was compared with stellate ganglion block (SGB) in patients undergoing both treatments. ISB seemed to be at least as effective as SGB for treatment of RSD/causalgia and may have some advantages over SGB. The role of somatic and sympathetic blockade is discussed.     

Updating upper extremity temporary prosthesis: thermoplastics.

Since 1989 amputees with upper-extremity burns have been fitted with a temporary prosthesis fabricated from low-temperature thermoplastic. Before 1989 conventional temporary prostheses were fabricated with plaster. The use of the thermoplastic material has produced a lightweight, cost-effective, modular system. No patients exhibited skin breakdown with the thermoplastic material. It appears that thermoplastics may be the next major breakthrough in terms of a design for a temporary upper-extremity prosthesis.     

Tendon reflex latencies in the upper extremity.

This study was aimed at establishing a baseline for the latency values of the biceps-brachii, triceps-brachii and brachioradialis tendon reflexes from the moment of elicitation by percussion of the tendon, to the appearance of the muscle action potential. The percussion hammer triggered the electronic sweep on the electromyograph oscilloscope, showing latency to the onset of the potential. Standard skin electrodes were used. Certain precautions were taken to avoid artifacts caused by skin movement. Thirty normal volunteer subjects, between the ages of 17 and 55 years, were examined. Biceps reflex latency values varied between 9 and 14 msec; with a mode of 11 msec and an average of 11 msec. Triceps latency values varied between 9 and 13 msec; with a mode of 11 msec and an average of 10 msec, and brachioradialis latency values varied between 13 and 20 msec, with a mode of 16 msec and an average of 16 msec.     

中文版上肢功能障碍问卷用于手与上肢外伤的信度和效度研究

摘要 目的：探讨中文版上肢功能障碍问卷(DASH)用于手与上肢外伤的信度和效度,为手与上肢外伤患者提供综合疗效指标的评估方法。 方法：招募手与上肢外伤患者964例参与研究。患者入院时进行DASH问卷自评,3天内进行问卷的第2次评估。采用Cronbach α信度系数、折半信度法、组内相关系数(intra-class coefficient correlation, ICC)进行问卷信度分析;采用相关分析和因子分析,进行问卷内容和结构效度的分析。 结果：①DASH问卷具有良好的内部一致性。DASH总分Cronbach α信度系数为0.969,其中ADL、症状、工作、休闲娱乐部分的Cronbach α信度系数分别为0.949、0.885、0.907、0.966。DASH总分的折半信度系数为0.904,其中ADL、症状、工作、休闲娱乐部分折半信度系数分别为0.932、0.867、0.867、0.955。②DASH问卷具有良好的重测信度。DASH总分的ICC值为0.875,95%CI为0.783—0.929,其中ADL、症状、工作、休闲娱乐部分的ICC值分别为0.79、0.846、0.889、0.92。③DASH问卷具有较高的内容效度,每项内容与DASH总分的相关性均显著,r为0.539—0.729(P=0.000)。④DASH问卷具有较好的结构效度,累积方差贡献率为66.369%。 结论：中文版上肢功能障碍问卷应用于手与上肢外伤患者的评估,具有良好的信度和效度,为临床提供了一种综合疗效指标的评估方法,值得推广应用。     

Chronic arterial insufficiency of the upper extremity.

When claudication or distal ischemia is significant, the treatment of choice for intrinsic arterial insufficiency of the upper extremity caused by atherosclerotic occlusive disease of the subclavian, axillary, or brachial artery with patent distal circulation is direct arterial surgery. Both endarterectomy and bypass procedures are utilized. In the 20 years from 1947 to 1967, 15 patients were operated on for such lesions and adequate circulation was restored in 12 patients treated by the direct method. Nine patients available for 1-year follow-up were cured of their symptoms; of the remaining three patients, one had amputation of an arm and two had sympathectomy with improvement. No hospital death occurred and morbidity was minimal. Although the diagnosis can be established on clinical grounds, arteriography is essential to ascertain the surgical procedure needed. Peripheral diseases involving the small arteries are clinically a more common cause of arterial insufficiency in the upper extremity; progress is slow and complications are infrequent. When ischemic complications exist, direct arterial surgery is not feasible and cervicodorsal sympathectomy is the usual form of treatment. Of 76 patients operated on for such disease, 74 underwent sympathetic neurectomy. The results were excellent, good, or satisfactory in 50 (78%) of the 64 traced patients. The remaining 14 patients had persistent or recurrent symptoms after operation. Removal of the stellate ganglion in addition to the second ganglion yielded better results and is indicated in recurrent or more cases.     

Iatrogenic nerve lesions of the upper extremity.

Thirty-three patients are presented who suffer from iatrogenic nerve injury of the upper extremity. Depending on the nature, duration, and degree of nerve injury, we performed neurolysis (16), direct nerve coaptation (4), and nerve grafting (13). Fourteen (70%) of 20 patients presenting with motor nerve injury achieved motor function against resistance. In 26 of 30 patients (87%) with sensory nerve involvement, at least some superficial sensory function was restored. Surgeons should be familiar with clinical and electroneurophysiological tests for early diagnosis of iatrogenic nerve injuries to allow early intervention for maximal nerve recovery.     

Rehabilitation robotics for the upper extremity: review with new directions for orthopaedic disorders

The focus of research using technological innovations such as robotic devices has been on interventions to improve upper extremity function in neurologic populations, particularly patients with stroke. There is a growing body of evidence describing rehabilitation programs using various types of supportive/assistive and/or resistive robotic and virtual reality-enhanced devices to improve outcomes for patients with neurologic disorders. The most promising approaches are task-oriented, based on current concepts of motor control/learning and practice-induced neuroplasticity. Based on this evidence, we describe application and feasibility of virtual reality-enhanced robotics integrated with current concepts in orthopaedic rehabilitation shifting from an impairment-based focus to inclusion of more intense, task-specific training for patients with upper extremity disorders, specifically emphasizing the wrist and hand. The purpose of this paper is to describe virtual reality-enhanced rehabilitation robotic devices, review evidence of application in patients with upper extremity deficits related to neurologic disorders, and suggest how this technology and task-oriented rehabilitation approach can also benefit patients with orthopaedic disorders of the wrist and hand. We will also discuss areas for further research and development using a task-oriented approach and a commercially available haptic robotic device to focus on training of grasp and manipulation tasks.

• Implications for Rehabilitation

• There is a growing body of evidence describing rehabilitation programs using various types of supportive/assistive and/or resistive robotic and virtual reality-enhanced devices to improve outcomes for patients with neurologic disorders.

• The most promising approaches using rehabilitation robotics are task-oriented, based on current concepts of motor control/learning and practice-induced neuroplasticity.

• Based on the evidence in neurologic populations, virtual reality-enhanced robotics may be integrated with current concepts in orthopaedic rehabilitation shifting from an impairment-based focus to inclusion of more intense, task-specific training for patients with UE disorders, specifically emphasizing the wrist and hand.

• Clinical application of a task-oriented approach may be accomplished using commercially available haptic robotic device to focus on training of grasp and manipulation tasks.

     

Total joint arthroplasty. Introduction to the upper extremity.

Total joint replacement in the upper extremity has developed in step with that of the lower extremity. The indications for treatment, the place of total joint arthroplasty in contrast to other forms of arthroplasty, and the criteria for patient selection have recently been classified. A number of problem areas are under biomechanical and clinical study, and most investigators are proceeding cautiously. In properly selected patients, however, prosthetic replacement offers great improvement in both relief of pain and joint function, and improvement should continue. The patient and physician should recognize the limitations that are inherent in any "artificial joint" replacement. Realistic expectations would be for improvement that approaches, but rarely achieves, normal function.