Musculoskeletal Disorders in OH Flashcards
What are work-related musculoskeletal disorders (WMSDs)?
A group of painful disorders of muscles, tendons, bones and nerves including carpal tunnel syndrome, tendonitis, thoracic outlet syndrome and tension neck syndrome.
They generally develop gradually due to overuse of involved structures.
They are one of the most common occupational disorders around the world.
Occupational Lower Back Pain
Lower back pain has a lifetime prevalence of 60 - 80%, and is the second most common cause of work-related ill health / claiming incapacity benefit.
Can be caused by physical exposures (lifting, bending, whole-body vibration, sitting) and psychosocial factors (low control, high demand, low job satisfaction). It is most common in construction workers, agriculture ad clinical health care.
In most cases, pathology is not defined (non-specific lower back pain). <10% of cases have identifiable pathology (e.g. nerve root compression).
X-rays and MRI are not useful in most cases, only if there is concern of serious spinal pathology (red flags: night pain, bladder/bowel dysfunction, saddle anaesthesia, carcinoma, progressive neurological deficit, fever, weight loss, age < 20 or >55, systemic steroid therapy, disturbed gait).
In more than 50% of cases, symptoms resolve within 4 weeks. Outcome is strongly influenced by psychological, workplace and cultural factors.
Yellow, blue and black flags in occupational lower back pain?
These are risk factors for chronicity and disability.
Yellow flags - psychological and behavioural
- negative attitude that back pain is harmful / disabling
- Fear avoidance behaviour + reduced activity levels
- Expectation that passive treatment is beneficial
- Tendency towards depression, low morale, social withdrawal
- Social or financial problems
Blue flags - Occupational psychological factors
- Poor job satisfaction
- Blaming working conditions
- Adverse job characteristics
Back flags - organisational and social factors
- Health benefits of insurance
- Litigation and sickness policies
Occupational Health management of lower back pain
- Refer those with red flag symptoms for urgent clinical review
- Otherwise - rehabilitation
- Encourage to stay active
- Physiotherapy
- Reassurance
- Advise early return to work
- Consider adjustments to job / redesign
Talk about Work-related Upper Limb Disorders (WRULD)
Upper limb and neck pain are common. Again, many have pain in the absence of clearly defined clinical pathology, however there are some distinct disorders (e.g. epicondylitis, carpal tunnel).
Medical management:
- NSAIDS / analgesics
- Shoulder disorders: physiotherapy, corticosteroid injections, exercise programmes
- Neck disorders: soft cervical collar, physio, heat pads, TENS, manipulation, acupuncture
- Elbow disorders: corticosteroid injections, pulsed ultrasound, wrist splinting to prevent dorsiflexion
- Tenosynovitis/peritendinitis: local heat, corticosteroid injection, splinting, surgical decompression, tenosynovectomy
- Carpal Tunnels: splinting, local corticosteroid injection, surgical release
Tell me about carpal tunnel syndrome
Caused by compression of the median nerve as it passes due to the carpal tunnel in the wrist, resulting from raised pressure in this compartment.
Risk factors:
- Female gender
- Pregnancy
- Obesity
- Age
- Occupations with repetitive hand or wrist movements e.g. vibrating tools / assembly line work
Symptoms of Carpal Tunnel?
Symptoms:
- Pain, paraesthesia or sensory loss in the median nerve distribution (lateral 3.5 digits. Note palm is spared)
- Symptoms are normally worse at night
Examination in Carpal Tunnel?
On examination:
- Tinel’s test: reproduction of sensory symptoms by percussing over the median nerve
- Phalen’s test: reproduction of sensory symptoms by holding the wrist in full flexion for 1 minute
- Weakness of thumb abduction / wasting of thenar eminence in late stages due to denervation atrophy of the thenar muscles (including Abductor Pollicis Brevis)
Diagnosis of Carpal Tunnel?
Carpal tunnel syndrome is a clinical diagnosis. If diagnosis is uncertain, nerve conduction studies may be useful to confirm median nerve damage.
Management of Carpal Tunnel Syndrome?
Initially conservative management:
- Wrist splinting (commonly overnight, to prevent wrist flexion)
- Hand physiotherapy
- Steroid injections into the carpal tunnel to reduce swelling
- Consider NSAIDs, though evidence is limited
Surgical treatment: if conservative measures have failed, surgical management would be Carpal Tunnel Release, to decompress carpal tunnel. Flexor Retinaculum is cut, reducing pressure on median nerve. Can generally be done as a day case under local anaesthesia.
Tell me about Adhesive Capsulitis - Frozen Shoulder
The glenohumeral joint capsule becomes contracted and adherent to the humeral head, resulting in shoulder pain and reduced range of motion of the shoulder.
- Adhesive capsulitis is more common in women
- Most common between ages of 40 and 70
- Higher likelihood of developing it in the contralateral shoulder, if you have previously had it in one shoulder
- It is associated with autoimmune thyroid disease and diabetes
Symptoms and diagnosis of Adhesive capsulitis?
Adhesive capsulitis roughly has three stages:
1) Painful stage
2) Freezing stage
3) Thawing stage
Patients generally present with:
- Generalised deep and constant pain of the shoulder + deltoid area, often disturbing sleep
- Associated joint stiffness and reduced joint function
On Examination:
- Loss of arm swing motion
- Atrophy of the deltoid muscle
- Generalised tenderness on palpation
- Limited range of active / passive motion (primarily external rotation and flexion of the shoulder)
Adhesive capsulitis is a clinical diagnosis. X-rays are generally normal. MRI can reveal thickening of the glenohumeral joint capsule.
Adhesive Capsulitis / frozen shoulder management?
Adhesive capsulitis is a self-limiting condition, though recurrence is not uncommon. Recovery generally take s months to years, and some patients will not recover their full range of motion.
Management:
- Education and reassurance
- Encouraging activity
- Physiotherapy / shoulder exercises
- Simple analgesia for pain
- consider corticosteroid injections
- If there is no improvement with prolonged engagement with conservative management could consider joint manipulation under GA +/- surgical release of the glenohumeral joint capsule
Tell me about Rotator Cuff Tendinitis?
Rotator Cuff Tendinitis Symptoms?
Management of Rotator cuff tendinitis?
