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CUMULATIVE TRAUMA DISORDER

CUMULATIVE TRAUMA DISORDER -

Description of mechanism of injury

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Not a diagnosis

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It is a class of Musculoskeletal disorders in which chronic discomfort, pain & functional impairment may develop over period of time as a result of frequent, sustained & repetitive movements

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Associated with rise in automation & specialization in work

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Faster work rates & redesign of jobs require a worker to do a single task or a very limited number of tasks tens of thousands of time everyday

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Who are affected?

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Occupations requiring repetitive & continuous use of their hands

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Computer keyboarding, repetitive assembly line work, repetitive crimping as in processing industries

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Clerical workers

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Athletes

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Musicians

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Dominant hand presents earlier

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Symptoms are confusing

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Attempts to define specific diagnosis are necessary

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Because = each disorder has a different cause, treatment & prognosis

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Does not have single initiating event

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Symptoms initially – subjective, non specific to Musculoskeletal system

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Initially ache present at work but disappears at rest

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If individual avoids repetitive work or the relevant work conditions that aggravate or precipitate the conditions are appropriately altered, CTD will resolve

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If exposure continues  symptoms progress  more defined to a specific disorder affecting a combination or a single component of the musculoskeletal system.

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Neural compression, inflammation of muscle tendon unit, vascular alteration Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER

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Cannot be viewed as circumscribed physical phenomenon alone

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Have a sociological, psychological & political impacts the patient’s progress & outcome

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Unproven etiologies, insidious onsets, few objective signs, variable symptoms

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Issue of legitimacy of the conditions & question their work status

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Impact of disorder on employers, unions, insurers, government agencies apart from individual & family

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Medical payment & reimbursement problems  Financial hardship  Psychological stress  Depression from physical effects 

Threat to persona, career & daily rhythm of life

TYPES OF CTDs 1. Tendinitis/Tenosynovitis –

Lateral epicondylitis,

Extensors

DeQuervain’s tenosynovitis – intersection syndrome, Extensor indicis proprius, ECU

Flexors – FCR, FCU, Trigger digits

2. Nerve compression syndromes –

Carpal tunnel syndrome

Cubital tunnel syndrome

Cervical radiculopathy

TOS

Anterior interosseus syndrome Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER –

Posterior interosseus syndrome

Pronator teres syndrome

Guyon’s canal syndrome

3. Pain syndromes -

Mayofascial pain syndrome

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Fibrositis

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Fibromyalgia

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RSD

4. Other -

Vibration white finger

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Arthritis

2. Overuse Syndromes 3. Repetitive Strain Injuries 4. Cervical Brachial Disorders

COMPONENTS OF THE EVALUATION PROCESS History

Subjective

Objective

Health history form

Current symptoms ROM

Sensory Provocative tests

H/o employment injury Pain status

Strength

Semmes- Weinstein Test

ADL status

Volume

Vibrometry

Palpation for trigger points, Stress tests Nodules, swelling Analysis of posture Work simulation

WORK RELATED RISK FACTORS FOR CTD 

Repetition

Vibration

High Force

Prolonged Static Positioning

Awkward Joint Posture

Direct Pressure Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER CUMULATIVE TRAUMA

When Force Is Applied To Same Muscle Or Muscle Group  Rapid, Repetitive & Forceful Movements  Inflammatory Response In The Tendon, Muscle Or Nerve  Localized Muscle Fatigue  Ischemia & Metabolic Change That Impairs Muscle  Enzyme Function  Muscle Cramp  Susceptible To Micro Tears & Inflammatory Changes  Pain During Work  Not Relieved By Rest  Severe Cases Sleep Disturbed

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER

FUNCTIONAL GRADING OF CTDS GRADE I

Pain after activity Resolves quickly with rest No decrease in amount or speed of work Objective findings usually absent

GRADE II

Pain in one site while working Pain is consistent while working, but resolves when activity stops. Productivity may be mildly affected May have objective findings

GRADE III

Pain in one or more sites while working Pain persists after activity is stopped Productivity affected & multiple breaks may be necessary to continue working May affect other activities away from work May have weakness, loss of control & dexterity, tingling, numbness, and/or other objective findings May have latent or active trigger points

GRADE IV

All common uses of hand/UE cause pain, which is present 50 – 75% of the time May be unable to work or works in limited capacity May have weakness, loss of control & dexterity, tingling, numbness, trigger pints, and/or other objective findings

GRADE V

Loss of capacity to use hand because of chronic, unrelenting pain Usually unable to work Symptoms may persist indefinitely

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER TREATMENT PHASE I TREATMENT = SYMPTOM CONTROL = STRENGTHENING 

Acute phase -

Decreasing inflammation through dynamic rest

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Splints – for immobilization, alone may relieve symptoms

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Removed 3 times a day for stretching of affected musculature, maintain or increase muscle length, avoid joint stiffness.

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E.g. extensor group in lateral epicondylitis

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Painful activities avoided during dynamic rest phase

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Massage = for edema control & reduction of pain

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Vibration contraindicated – contribute to inflammatory problems

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Combined with cortisone injections to reduce inflammation

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Icing, contrast baths, ultrasound phonophoresis, Interferential, high voltage electrical stimulation  reduce pain & decrease inflammation

NSAIDS

Exercise phase (sub acute phase) -

Warming up of muscles by slow stretching

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Controlled progressive exercises

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PRE = Resistance at the end of range

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Tennis elbow armband = over extensor muscle belly  limit full excursion of the muscle during active use of the arm

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Resistance should be increased slowly = should not cause an increase in pain

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Stretching three times a day = before activity = indefinite time

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Proper body mechanics = long term control of inflammatory problems

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Aware of what triggers symptoms

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Learn early intervention if symptoms reappear

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Icing, stretching, modified activities, correct body mechanics

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Massage = aid in pain reduction, maintain tissue mobility

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER -

KEY = patient learn self management techniques & take an active role in their treatment

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Evaluation of job site, tools used, hand position during work activities

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Modification of the equipment used

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Strengthening of the dominant muscle groups & their antagonists

PHASE II TREATMENT = CONDITIONING (final phase) –

Return to work

Work conditioning or work hardening

BTE work simulator

Tool and/or work site modifications = help prevent reinjury

Ergonomic modifications = different type of handle on a tool, change in height work table

Work out with patient and employer

Return to work instructions should be well coordinated & communicated to both supervisor & patient to prevent misunderstanding

Light duty

Monitor periodically

TENDINITIS -

Occupational illness

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Because of overuse

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Some use CTD, RSI, Overuse syndrome and tendinitis synonymously

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Other “tendinitis differ from overuse syndrome”

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Tendinitis = inflammation of tendons & muscle tendon attachment, spontaneous in onset, after a single traumatic event, sometimes after repetitive use, pain well localized with swelling of the tendon sheaths, local tenderness & induaration, weakness secondary to pain

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CTD = due to micro trauma that results from the cumulative effect of repetitive stress on tissues, occur after long hours of repetitive use in unusual positions, pain diffuse &

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER poorly localized, swelling in the muscle bellies & musculotendinous junction or muscle origin, weakness is general & tenderness is subtle & diffuse -

Tendons are vulnerable – as they are relatively avascular

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Repetitive micro trauma  cell damage with acute inflammation  chronic

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Vicious cycle of pain, instability & dysfunction

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Biomechanical defects  weakness, inflexibility, scar tissue

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Early treatment of an acute traumatic case typically has a better prognosis than after the injury has become chronic.

EVALUATION -

An overaggressive evaluation that provokes pain can set the treatment timetable back significantly & undermines the trust of & rapport with the patient.

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Cervical screening  to look for proximal causes of distal symptoms

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Compare both extremities

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Assess pain – local, diffuse

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Swelling

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Sensory changes

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Loss of function

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Pain = with AROM, with resistance, with passive stretch of the involved structures

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Compare subjective & objective findings

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Symptoms often elusive, occur dynamically or intermittently

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Angry or hostile  depressed over their loss of function

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Identify activity causing pain

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Ergonomic related activity analysis

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Observe actual activity or simulated

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Identify ergonomic risk factors = forceful, rapid, repetitive movements

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Repetitive movement = if performed > once every 30 seconds or for > half the total work time

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Additional risk factors = history of soft tissue problems, pressure & shear forces, stress & muscle tension, hyper mobility

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER TREATMENT -

Treat acute phase with rest, ice, compression & elevation of the involved structures

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Anti inflammatory physical agent modalities

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Splinting individualized = beneficial, least problematic at night

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Immobilization  disuse

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Soft supports are helpful

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Try to avoid pain

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After inflammation subsides, upgrade treatment to restore normal function through gradual mobilization balanced with rest

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Tendon gliding exercises in pain free range appropriate to particular structures involved

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Isometric exercises with gentle contractions  isotonic low load, high repetition strengthening in short arcs of motion

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Increase the arc of motion & modify proximal positions to be challenging if appropriate for work simulation

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Gentle flexibility exercises in pain free range

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Difficult to learn = slow & pain free passive stretch

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Aerobic exercises & proximal conditioning

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Prevent reinjury through education

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Simulation & biofeedback promote biomechanically efficient UE use

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Teach the patient to avoid reaching & gripping with an extended elbow, flexed or deviated wrist.

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First solve easily recognizable issues = obviously poor posture, trunk twisting with reaching & lifting

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Instruct in pacing to avoid fatigue that leads to reinflammation

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Unsupported UE movement, nonsymmetrical UE use, nonfrontal trunk or UE alignment, unilateral UE work = taxing

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Distal symptoms may recover well by focusing treatment on posture, conditioning & proximal strengthening

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Use hand-held tools with ergonomic design Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER -

Ergonomic adjustments = lift bilaterally with proper biomechanics, use of a telephone headset instead of laterally flexing the neck & elevating the receiver

Tendinitis and Tenosynovitis CYCLE Normal Activity  Overuse  Micro trauma  Swelling  Pain  Limitation in movement  Rest  Disuse  Weakness  Normal activity -

Combination of

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Localized pain,

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Swelling,

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Pain with resisted motion of the affected musculotendinis unit

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Limitation in motion

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Weakness

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Crepitation of the tendons Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER -

Symptoms reproduced with activity or wok simulation

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Isometric grip strength may be normal

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Wrist, forearm strength decreased, out of balance

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Dynamic grip strength = more limited because tendon gliding may increase inflammation & pain. -

Muscle imbalance  Positioning & substitution patterns  Worsening or spreading of symptoms

Lateral epicondylitis -

Tennis elbow

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Involves extrinsic extensors at their origin

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ECRB is most commonly involved

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Pain at the Lateral epicondyle & extensor wad (proximal portion of the extensor muscles)

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Differential diagnosis = radial tunnel syndrome = tenderness more distally over the radial tuberosity = middle finger test positive

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Middle finger test positive = pain secondary to resisting the MF proximal phalanx while the patient maintains elbow extension, wrist neutral, MP extension

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Percussion test = percussion distally over the superficial radial nerve  elicits Paresthesias

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Exercises = proximal conditioning, scapular stabilizing

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Build up handles

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Splint = support wrist in extension, night, neutral to 30 degrees

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Counterforce strap = a strap placed over the extensor wad to prevent full muscle contraction & to reduce load on the tendon during the day with activity

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Avoid applying the counterforce strap too tightly; this can cause radial tunnel syndrome

De Quervain’s Disease -

Tendinitis involving APL, EPB tendons at the first dorsal compartment Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER -

Most common

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Positive Frinkelstein’s test = exquisite pain with passive wrist deviation while flexing the thumb

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Golfers, knitters, racquet sports players, mail sorters, filing clerks

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Thumb posture in sustained hyper abduction may be provoking]

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Differential diagnosis = carpometacarpal arthritis, scaphoid fracture, intersection syndrome, FCR tendinitis

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Avoid wrist deviation, while pinching

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Built up handles

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Splint – forearm based thumb spica, leaving IP free

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Watch for irritation from the radial splint edge along the first dorsal compartment

Medial epicondylitis -

Golfer’s elbow

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Involves extrinsic flexors at their origin, FCR most common

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Pain at medial epicondyle & flexor wad (the proximal portion of the flexor muscles),

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Pain with resisted wrist flexion & pronation

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Exercise to promote proximal conditioning

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Avoid end ranges with forceful activity

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Provide build up handles

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Splint = maintain the wrist in neutral

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Counterforce strap over flexor wad

Extensor Carpi Ulnaris Tendinitis -

Pain & swelling distal to the ulnar head

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Associated with repetitive ulnar deviation motions

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Subluxation of ECU tendon elicits a painful snap with forearm supination & wrist UD

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Differential diagnosis = instability of distal radio-ulnar joint, ulno-carpal abutment or tear of the triangular fibro cartilage complex (TFCC)

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Avoid UD with activities

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Splint = forearm based gutter or wrist cock up splint

Flexor Carpi Radialis Tendinitis -

Pain over FCR tendon just proximal to the wrist flexor creases Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER -

Differential diagnosis = volar ganglion, arthr itis of scapho trapezio trapezoid joint

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Splinting = wrist cock up in neutral or position of comfort

Flexor Carpi Ulnaris tendinitis -

More common than FCR tendinitis

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Pain along volar ulnar side of the wrist

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Inflammation where FCU inserts at the pisiform

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Differential diagnosis = pisiform fracture, pisotriquitral arthritis, TFCC injury

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Avoid wrist flexion with UD

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Splint = forearm based ulnar gutter

Extensor Pollicis Longus tendinitis -

Drummer boy palsy

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Associated with activities requiring repetitive use of thumb & wrist as seen in drummers

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Pain & swelling at Lister’s tubercle (a dorsal prominence at the distal radius around which EPL passes)

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Less common

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If untreated tendon rupture

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Rupture of EPL in RA or Colles’ fracture

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Identify & eliminate provocative activities

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Enlarge the girth of utensils

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Splint = forearm based thumb spica that includes the IP

Intersection syndrome -

Pain, swelling & crepitus of the APL & EPB muscle bellies approximately 4cm proximal to the wrist, where they intersect with the wrist extensor tendons (ECRB, ECRL)

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Associated with repetitive wrist motion = weight lifters, rowers, canoers

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Differential diagnosis = de Quervain’s disease, both can occur concomitantly

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Avoid painful or resisted wrist extension & forceful grip

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Splinting = same as de Quervain’s, forearm based thumb spica, leaving IP free

Flexor tenosynovitis -

Trigger finger Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER -

Stenosing tenosynovitis of the digital flexor

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Usual cause = stenosis at the A-1 pulley, which is part of the fibro-osseous tunnel that prevents bow-stringing of the digital flexors

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Tenderness over A-1 pulley

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Pain with resisted grip, painful catching or locking of the finger in composite flexion

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Origin can be inflammatory or not

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Strong association with diabetes & RA

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Local anesthetic & steroid injected into the flexor sheath

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Injection can be repeated a few times

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Splinting MP in neutral to prevent composite digital flexion (preventing triggering) while promoting tendon gliding

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Place & hold fisting that avoids triggering

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Build up handles

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Padded gloves

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Pacing strategies

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Instruct to avoid triggering ď‚Ž reinflames the tissue

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Surgically release the A-1 pulley

NERVE COMPRESSION SYNDROMES -

Carpal tunnel syndrome

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Symptoms – night pain, severe enough to waken the patient, tingling in the thumb & long fingers, wasting of thenar muscles caused by pressure on motor branch (advanced)

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Early recognition by nerve evaluation

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Pressure on the median nerve = as it travels beneath the TCL at the volar surface of the wrist

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Associated with increase pressure in the carpal canal because of 1. Trauma 2. Edema 3. Retention Of Fluids As A Result Of Pregnancy 4. Flexor Tenosynovitis Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER 5. Repetitive Wrist Motion 6. Static Loading Of The Wrist -

Conservative treatment = attempted first

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Splinting wrist in no more than 20 degree extension,

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Custom fabricated semi flexible splint, neoprene splint rather than completely rigid splint = to provide support, allowing small amount of flexion & extension for greater functional use

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Contrast baths to reduce EDEMA

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Edema – for sitting, many find increased comfort by resting the forearms & hands on a pillow placed on a lap

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How to position their hands & arms when walking

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Wearing isotoner gloves

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Activity analysis

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Ultrasound phonophoresis = to reduce inflammation

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Icing technique

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Specific strengthening exercises of the wrist, fingers & thumb = when pain & inflammation have been controlled

ACTIVE & PASSIVE ROM -

Assess the trunk & limb ROM

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Alteration in response to pain, lack of movement in one location

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Deficient movement in the spine & the extremities

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Neck, shoulder affectation for wrist & hand CTD = prolonged postural alteration

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Discourage simultaneous movement or positioning in the same direction across both the joints in two-joint muscles in the symptomatic region

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Stabilize the wrist in neutral position to reduce tension of the long flexors & extensors

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During wrist motion digits are held in relaxed posture

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Writing = learns to use this pattern by using 25 – 30 degree inclined board to write on with an enlarged pen

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Taught to adjust the height of an object to be worked on, wrist is positioned in neutral while the hand is fisted or is pinching Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER

MAYOFASCIAL PAIN & FIBROSITIS -

Pain elicited by activation of trigger points within the muscles & resulting in pain referred to a distal area

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Poor posture & positioning of the body out of normal alignment

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Careful examination of the patient & his/ her normal daily activities

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Observe the patient performing the activity rather than rely on a verbal description

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Mayofascial pain should be considered = where direct treatment of the painful area does not relieve the pain

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Meticulous evaluation of trigger points

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Mapping of trigger points &referral areas documented

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Trigger points should be treated NOT referral area.

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Ice, ultrasound phonophoresis

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Friction massage, TENS

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Activity analysis = to relieve the stresses on the affected tissues

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Altered or limited ability to apply pressure, lift, carry & manipulate components of

ADL

usual ADL tasks -

Detailed inquiry = to determine the ability to eat, dress, perform personal hygiene, use transportation, maintain at home, write, use of telephone/ mobile phone, keyboard on the computer/mobile phone, and do leisure activities

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Goal = restoration of safe ADL performance

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Methods of joint protection & energy conservation to avoid precipitating & aggravating postures & movements

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Significant functional impairment, fine motor coordination tasks

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Adaptive equipment

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Creative problem solve = innovative solutions to manage fasteners, change purses, dental floss, pen or pencil

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B/o weakness = lifting capacity limited to 3 or 5 lb ď‚Ž backpack or waist pack that relies on the support of larger muscles of shoulder & trunk to carry groceries, laundry, books, musical instruments Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER -

Lower endurance = affects sustained static patterns, difficulty holding onto newspaper for more than a few minutes  reading the paper on a table

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Spontaneously dropping things  use paper or plastic products in kitchen, to work over a surface to minimize spillage, monitor hands visually during tasks

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Lower tolerance to vibration = limit the amount of time that person can handle the steering wheel in the car  more frequent balancing of tires

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Vibration of hair dryers = irritating to the hands  mount on the wall

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Improved endurance  ADL methods upgraded  but adhere to the biomechanical principles for joint protection

WORK & LEISURE -

People are affected in the beginning or the first half of their career cycle

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Ability to perform physically active sports & ability to participate in travel with family & friends hindered

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Sedentary activities like reading & playing cards – difficult to do

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Unable to hold book for long

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Shuffling & holding cards not possible without adaptations

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Vital to identify ways to assist to either continue with important recreational activities

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Help select activities which are relaxing & meaningful

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Swimming, yoga, ballet

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Pain profile – to document localized & referred pain pattern & duration & intensity

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Some describe onset from a specific activity/ movement

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Pain reaction delayed following a precipitating factor

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Advanced symptoms = always in pain, but intensity varies, not related to

PAIN

activity/position -

Local heat through whirlpool, fluidotherapy, paraffin, heat packs

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Deep heat – acoustic vibration (ultrasound), electrical stimulation such as galvanic, iontophoresis, TENS

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Home programme – cooling with ice packs, local moist heat applications, TENS Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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CUMULATIVE TRAUMA DISORDER

SCAR MANAGEMENT Progression of inflammatory process & recurrent micro-trauma  Scarring & shortening of the muscle-tendon tissue  Prevent inflamed & painful muscle-tendon unit from becoming fibrotic  Deep massage & ultrasound to stimulate fibroblast activity on the inflamed tissue  Supportive static splints – prevent inflamed regions from stiffening in shortened position

INTERVENTION MODELS 

Vocational model

Case management

Industrial model

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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cumulative trauma disorder  

notes for fourth both

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