Occupational Disorders of the Upper Extremities in the past usually consisted of lacerations, fractures, sprains and amputations. In the last two decades industrialized countries have witnessed a very different kind of injury pattern, termed “Cumulative Trauma disorder” (CTD). These conditions are poorly defined and too often poorly managed.
Terminology & Definitions
The first major stumbling block in the management of these conditions is the terminology used. The combination of words, repetitive, cumulative, overuse, occupational is interchanged with disorder, injury, strain, and/or trauma. All these terms are synonymous. Yet, none of the terms represent a diagnosis.
Examples of Cumulative Trauma Disorders
- Overuse Syndrome
- Shoulder-Arm Syndrome
- Occupational Stress Syndrome
- Repetitive Trauma Syndrome
- Occupational Cerviobrachial Disorder
- Occupational Disorder
- Cumulative Trauma Syndrome
- Repetitive Strain Injury
- Repetitive Motion Disorder
- Upper Limb Syndrome
The terms above are simply descriptive. They should not be used as an accepted diagnosis nor a basis for treatment or disability. When a condition is improperly defined, the outcomes are predictably frustrating, contentious ad expensive. Repetition has been referred to as a factor that results in the causation or aggravation of the above stated disorders. To date, the medical literature cannot support what is defined as “repetitious”, and what “safe rates” would actually be. The general restriction of “no repetitive work” should not be accepted. This does not mean that there are not well-recognized disease entities that do occur in the workplace. Certain patterns of hand activity such as posture of the wrists, the forces involved, and the production rate may cause a disease pattern. But, the diagnosis of any condition must be based on what can be observed, measured, reproduced and objectively confirmed.
Diagnosing the Problem
The patient given the diagnosis of “Overuse Syndrome”, often presents discomfort, nonspecific tenderness, and no physical or objective findings. There is also variability in findings among different examining physicians. A diagnosis such as this starts the cycle of referrals, treatment, and medical restrictions that have no foreseeable end. Some of the most common work related conditions are listed below. These do fulfill the criteria of being observable, objectifiable, measurable and reproducible.
Common Work-Related Conditions
They are well established in the medical literature. They have treatment protocols and in most cases, predictable outcomes. It is extremely important that the determination of work relatedness as it applies to specific medical conditions are determined at the onset. Initial management often determines the outcome.
Appropriate referral in a timely manner to a specialist decreases disability time
Patients who are bounced around from physician to physician, having multiple tests prolonged therapy and restricted from work, will often develop a “disability psychology” that is greater than the actual medical problem.
The Role of Case Managers
A case manager helps monitor the care of the patient and facilitate communication between the employer, treating physician, and insurance carrier. The accountability of all parties is necessary. It is important to critically evaluate your treating physicians. Your doctor should be objective, consistent and open to the assistance of case managers. “Red flag conditions” that should be watched for are outlined below. Should these occur, second opinion evaluations are important in the further management of the injured worker. Therapy with a trained occupational or physical therapist is helpful, however this can be abused and therapy without direction or goals is nonproductive. When considering the conditions like carpal tunnel, cubital tunnel, and trigger fingers/thumbs, therapy beyond six weeks should be re-evaluated.
Red Flag Conditions
- Thoracic Outlet Syndrome
- Fibromyositis of Fibromyalgia
- Myofascial Pain Syndrome
- Reflex Sympathetic Dystrophy
- Chronic Tendonitis
The Employer’s Role
The employer also plays an essential role in the management of these conditions. The final goal is to return the injured person to their job. If that is not available, they need to be returned to some type of job as soon as possible. The ability to modify the job, to provide the injured worker the opportunity to do as much as possible within medical restrictions is important.
Though this information is not oriented as a thorough discussion of ergonomics, prevention does need to be mentioned. Pre-employment examination may define whether there are pre-existing conditions. Preventative measures include gradual adjustment to jobs, rotation of jobs in high-risk areas and training in how jobs should be performed. Exercise and ergonomic evaluation of tools and patterns of activities are also important. The management of CTD does not need to be a mystery. A well-organized approach in which all parties are communicating with a common goal to return the injured workers to his job should result in a favorable outcome.