Development of a Physical Examination for a Company-Based Management Program for Work-Related Upper Extremity Cumulative Trauma Disorders

The purpose of this project was to develop a streamlined upper extremity examination to be used in a company-based upper extremity CTD management program. Thirty-six symptomatic employees were examined by an occupational health nurse and categorized into those requiring further medical evaluation or those appropriate for conservative management. Backward logistic regression showed that the Appearance and Symmetry (AS) and the Neurological and Special Tests (NST) sections of the examination together explained 86.1% (p = 0.002) of the nurses categorical decisions. Based on these preliminary development data, a short screening examination was proposed.     

Cognitive-Behavior Therapy in the Management of Upper Extremity Cumulative Trauma Disorder

Cognitive-behavioral techniques have a great deal to offer in the prevention and remediation of upper extremity cumulative trauma disorder (CTD) in the workplace In relation to prevention, cognitive-behavioral methods offer promise as adjuncts to educational programs and ergonomic practices that aim to increase workers' use of safe work postures, movements, and procedures. Cognitive-behavior therapy (CBT) is also an important component of the rehabilitation process for the minority of workers who proceed to a chronic pain condition. However, CBT forms just one aspect of the rehabilitation process, along with multidisciplinary interventions that tackle physical fitness, ergonomic factors, and work practices. CBT techniques, such as goal setting, problem solving, cognitive restructuring, attention diversion, communication skills, and assertiveness training, aim to enhance coping skills and reduce psychopathology and disability. As each patient presents with a different pattern of cognitive and behavioral strengths and weaknesses, an individualized assessment is important. This will permit the development of an individually tailored approach to CBT as part of the rehabilitation process.     

Multicomponent Intervention for Work-Related Upper Extremity Disorders

Although several multidimensional models have emerged to explain the development, exacerbation and maintenance of work-related upper extremity disorders and disability, there is a paucity of data on the application of these models for the development of worksite-based prevention and management programs. Sign language interpreting is an occupation associated with increased risk for upper extremity symptoms. Ergonomic, work organization, work style, and work-related and individual psychosocial factors have been demonstrated to play a role in the exacerbation of symptoms and lost time in this group. Therefore, it was hypothesized that an intervention directed at reducing the impact of these factors would be associated with reductions in the number of upper extremity cases/year and associated lost time and health care costs in a group of full-time sign language interpreters. Subjects included 53 symptomatic and asymptomatic interpreters working at the National Technical Institute for the Deaf. The intervention (eleven 1.5-hr group sessions) was designed to 1) reduce musculoskeletal overexertion by reducing workload and biomechanical strain, while increasing flexibility and endurance through tailored exercise and preinterpreting warm ups, 2) improve the ability of workers to manage job stress and musculoskeletal pain, 3) reduce biomechanical exposure through work organization and work style changes, 4) alter organizational sources of stress by improving supervisor's managerial skills to address work related upper extremity problems and provide increased supervisor support, and 5) educate workers and supervisors regarding the optimal utilization of health care resources, given the present state of the art in terms of clinical evaluation and management. Results indicated a 69% reduction in the number of cases reporting upper extremity problems in the 3 years following the intervention. Indemnity costs were reduced by 64% and were maintained over the next 2 years. Health care costs followed a similar, although smaller magnitude, change. Despite this reduction, a partial rebound in all outcome measures was observed in Year 3 postintervention. This rebound followed a progressive increase in workload over the 3-year follow-up period.     

Work-related musculoskeletal disorders: Comparison of data sources for surveillance

Work-related upper extremity musculoskeletal disorders “associated with repeated trauma” account for more than 60% of all newly reported occupational illness, 332,000 in 1994 according to the U.S. Department of Labor. These numbers do not include, for example, those disorders categorized as “injuries due to overexertion in lifting,” approximately 370,000. Early identification of potential disorders and associated risk factors is needed to reduce these disorders. There are a number of possible methods for conducting surveillance for work-related musculoskeletal disorders (WMDs) based on health outcome: workers' compensation, sickness and accident insurance, OSHA 200 logs, plant medical records, self-administered questionnaires, professional interviews, and physical examinations. In addition, hazard surveillance based on evaluation of job exposures to physical stressors by nonoccupational health personnel is possible. As part of a large labor-management-initiated intervention study to reduce the incidence of WMDs in four automotive plants, we were able to compare the strengths and limitations of each of these surveillance tools. University administered health interviews yielded the highest rate of symptoms; combined physical examinations plus interview (point prevalence) rates were similar to self-administered questionnaires (period prevalence) rates. Plant medical records yielded the lowest rate of WMDs. WMD status on self-administered questionnaire and on physical examination were associated with risk factor exposure scores. This study suggests that symptoms questionnaires associated with risk factor exposure scores. This study suggests that symptoms questionnaires and checklist-based hazard surveillance are feasible within the context of joint labor-management ergonomics programs and are more sensitive indicators of ergonomic problems than pre-existing data sources. Am. J. Ind. Med. 31:600–608, 1997. © 1997 Wiley-Liss, Inc.     

Basis for a Functional Capacity Evaluation Methodology for Patients with Work-related Neck Disorders

Background Neck pain is a common musculoskeletal complaint and a relationship with reduced work-related functional capacity is assumed. A validated instrument to test functional capacity of patients with neck pain is unavailable. The objective of this study was to develop a Functional Capacity Evaluation (FCE), which is content valid for determining functional capacity in patients with work related neck disorders (WRND). Methods A review of epidemiological review literature was conducted to identify physical risk factors for WRND. Results Evidence was found that physical risk factors contribute in development of WRND. Physical risk factors were related to repetitive movements, forceful movements, awkward positions and static contractions of the neck or the neck/shoulder region. An FCE was designed based on the risk factors identified. Eight tests were selected to cover all risk factors: repetitive side reaching, repetitive reaching overhead, static overhead work, front carry, forward static bend neck, overhead lift and the neck strength test. Content validity of this FCE was established by providing the rationale, specific objectives and operational definitions of the FCE. Conclusions Further research is needed to establish reliability and other aspects of validity of the neck-FCE.     

Preliminary Evaluation of the Generalized Work Distress Scale in Patients With Work-Related Upper Extremity Disorders

This study evaluated the reliability and construct validity of the Generalized Work Distress Scale in 207 patients attending a specialty clinic with work-related upper extremity disorders. Factor analyses were conducted and compared to the original developmental study confirming a two-factor solution: an internal factor related to Work-Related Dysphoria and an external factor related to Work-Related Support. Reliability (internal consistency) of factors was high (Cronbachs = 0.87 and 0.89). The Work-Related Dysphoria factor was more related to self-reported global depressed mood and self-reported upper extremity functional disability, than was Work-Related Support. This study provided preliminary support for the use of this scale in patients with work-related upper extremity disorders and consideration to depressive symptoms in these patients. Further investigation of the psychometric properties of this scale and its predictive validity are required.     

Transitions in self-reported musculoskeletal pain and interference with activities among newspaper workers

Active surveillance of symptoms and disability due to musculoskeletal disorders (MSD) in working populations can map individual transitions in symptom intensity or disability level. Using repeat surveys, this study examined if aetiological risk factors for new symptoms or disability, measured by interference with activities, were similar to prognostic risk factors for subsequent outcomes of symptoms and disability. This paper reports on 379 Toronto newspaper workers who completed questionnaires in 1996 and 1997. Questions on pain/discomfort during the last year, episode frequency and duration formed the basis for constructing three mutually exclusive symptom levels: noncases (Level 1); mild cases (Level 2); and more severe or frequent pain cases (Level 3). A similar construction of overall interference levels was based on the frequency with which musculoskeletal pain/discomfort interfered with daily, recreational, social and family activities, or ability to do one's job during the previous 12 months. The last was also examined as work interference alone. Levels of symptoms were cross-tabulated by overall and work interference at the two time points and Markov models of transitions between states were formulated. Results indicate that period prevalence of symptoms and overall interference increased between phases, though only significantly for symptoms (Levels 2 and 3, 65.7–70.7%, p = 0.04), while work interference was unchanged (17.9–17.0%). Equivalent proportions of workers improved as worsened in symptoms (21.1 and 22.4%, respectively), overall interference (16.7 and 17.8%), and work interference (7.4 and 6.6%). The only significant predictor for those without work interference at time one was job tenure, which was protective against work interference (Odds Ratio (OR) 1.06, 95% Confidence Interval (CI) 1.01–1.12). Among those who had more severe/frequent symptoms at time one, lack of improvement over time was predicted by longer job tenure (OR = 0.92 per year, CI: 0.87–0.97), greater psychological demands of work (OR = 0.65 per point, CI: 0.51–0.84) and marginally by greater upper extremity disability score. At time one, women with work interference were more likely to have persistent interference at time two (OR = 7.22, CI: 1.57–33.20). Suggestive findings included opposite effects of social support at work: reduced risk of development of new symptoms but increased risk of persistence at the highest symptom level.     

Work-related cumulative trauma disorders of the upper extremity: navigating the epidemiologic literature

BACKGROUND: Cumulative trauma disorder of the upper extremity (CTDUE) is an umbrella term used to describe disorders resulting from repeated use of the upper extremity over time rather than a specific incident. The primary purpose of this article is to summarize the literature regarding the rate of work-related CTDUE, while drawing attention to the various factors contributing to the wide range of reported findings. METHODS: The Cumulative Index to Nursing and Allied Health and Medline databases were searched for articles focusing on etiology or rates of occurrence of work-related CTDUE and their findings were summarized. RESULTS: Potential reasons for rising rates, a gender differential, and the substantial range in rates and rate ratios are delineated and important factors to consider when interpreting rates derived from workers' compensation data are detailed. CONCLUSIONS: Future research should attempt to correctly identify more specific categories of CTDUE in well-defined and accurately-quantified "at risk" populations to provide more meaningful information regarding the epidemiology of CTDUE and the effectiveness of control activities.     

Integrative interventions for MSDs: Nature, evidence, challenges & directions

Background: When applied to workplace interventions, integrative may be seen in various ways, requiring elucidation. Methods: Identification of primary studies through systematic reviews, limited bibliographic literature searches, the Cochrane Occupational Health Field database on intervention studies, and authors’ files. Focus was 2000 on. Categorization according to the Cochrane classes and lenses on integrative. Synthesis as narrative review. Results: Examples of each lens on integrative were uncovered: biomechanical and psychosocial, multiple component, primary and secondary prevention, organizational, and system. Each contributed different understanding to the potential impacts on different knowledge, exposure, behavior, health and administrative outcomes. Conclusions: Considerable opportunities exist to expand the range of integrative interventions, particularly at the organizational and system levels, and incorporate a combination of knowledge transfer and exchange with intervention evaluation.     

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. (This article is a US Government work and, as such, is in the public domain in the United States of America.) © 1996 Wiley-Liss. Inc.