occupational shoulder injuries - american college of ... · occupational shoulder injuries: a...

4/2/2014

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Keeping America on the Job! Select Medical Outpatient Division Family of Brands

©SelectMark 2014

Occupational Shoulder Injuries: A Physical Therapist’s Perspective

Katie McBee, PT, DPT, MS, OCS, CEAS

David A. Hoyle, PT, DPT, MA, OCS, MTC, CEAS

2 | Hoyle/McBee- Occupational Shoulder Injuries: A Physical Therapist’s Perspective

Disclosures/Conflicts of Interests-

Mr. Hoyle and Ms. McBee indicate they are both employed by Select Medical which is the largest provider of outpatient physical therapy services in the United States. Neither has a financial interest in Select Medical outside of their employment with the company. Neither has any other financial or conflicts of interest as defined by ACOEM to disclose related to this presentation.


Shoulder Injuries

13.6% of all workplace injuries are shoulder injuries1

Median days away from work are the greatest for shoulders than any other body part at 24 days.1

NCCI study looking at 4.2 million claims from 1996-2000 demonstrated shoulder injuries are the most costly in W/C.2

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Prevalence

In working population prevalence of UE symptoms is 20-30%3.

Prevalence in general population of 15.4% in Men and 24.9% in women. 13

Prevalence of chronic pain is 41%. Most common In the 45 to 64 year old age group.14

50% of new episodes of shoulder pain show a complete recovery in 6 months, 60% at a year. 9,12


Shoulder Injury causes

External Physical Risk factors

Personal Risk Factors

Pyschosocial Risk Factors


External Physical Risk Factors

Repetitive Mechanisms 8,9

High Force Demands- Specifically with the hands8,10

Work Related Posture-Duration, Awkward or Extreme 8, 10

Vibration 9

Computer Work 4

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Personal Risk Factors

Female gender5,6,7

Obese 21

Age 9

No physical activity 15

Sleep disturbances 16,17

Smoking 16,17

Psychosocial risk factors


Psychosocial Risk Factors

Work related Stress or just Stress 6, 8

High Productivity Demands 6

Low job control11

Low influence 11

High quantitative demands 11

Depressive Symptoms 18

Poor Job Satisfaction 19

Low social support or dislike of supervisor


What is the easiest shoulder injury to manage?

The one you prevent.

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Preventative Interventions

Ergonomic preventative strategies 4

Change employee behavior 25

Interchange the computer input device for VDT users 26

For sedentary workers promote physical activity during off time 15

Light resistance work outs may benefit office workers 27


Case Study

MD’s with new EMR System

6 MD’s reporting varying M/S pain, UE dominant for most


Case Study

Risk Factors Awkward postures Repetitive postures Sustained postures High work demands Low control Dissatisfaction with

Supervisor

Interventions used Headaches- new glasses R arm pain N/T- keyboard

tray B shoulder pain- new

chair, keyboard tray and foot rest

R shoulder impingement- new desk area so no cross body reaching

Move mouse to existing tray.

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Poor Prognosis 20, 9, 23

Heavy material handling, Vibrating tools, Hands above shoulder level

Pyschosocial risk factors

Duration of symptoms

Severe pain

High pain catastrophizing scores predict poor prognosis

Previous history

High disability scores at baseline

Job Dissatisfaction


Centralized Pain

Consider date of onset

Pain distribution does not match structure related patterns

Pain patterns are unpredictable and tied with emotions, illness, stress, etc.


Etiology of Shoulder Pain

The painful tissues resulting in the report of shoulder pain (lateral arm pain) are primarily thought to be part of the Gleno-humeral joint.

Rotator Cuff Tendons

Long Head of the Biceps

Glenoid Labrum

Sub-Acromial Bursae

Joint Capsule

Joint surface

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Factors Leading to Nociception from Glenohumeral Tissues

Intrinsic

Rotator Cuff Tendonpathy

• Tendinitis

• Tendinosis

• Tears

Biceps Tendonopathy • Tendinitis

• Tendinosis

• Tears

• SLAP Lesions

Extrinsic

Scapular Dyskinesis


Tendinopathy

Tendinitis Thought to be symptomatic

Inflammatory markers present

• Postaglandin E2

• Leucotiene B4

Normal collagen matrix • Organized fiber matrix

• Firm red Tissue

• Tight collagen bundle formation.

Lack of neovascularity.

Tendinosis May or may not be

symptomatic

Absence of inflammatory markers

Degnerative collagen matrix

• Disorganized fibers

• Soft, yellow or brown tissue.

• Loss of tight collagen bundle formation.

Neovascularity present.


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Physical Therapist Perspective Working with other Medical Providers

Is it a problem amenable to physical therapy?

Is it neuromusculoskeletal and movement related?

Is it coming from within the shoulder joint.

Screen above and below.

Is there pain with passive motion?

Joint or noncontractile element of contractile structures (tendon, bursae, cartilage, labrum).

Is there pain with resistance?

Tendon, possible muscle(less common).


Level 3

Rehabilitation Classification

Level 2

Pathoanatomic Dx

(Specific Phys Exam)

Level 1

Screening

History, Basic Physical Exam

Red, Yellow, Blue and Black Flags

Appropriate for Physical Therapy

Symptoms Originating from Shoulder

Symptoms Not Originating from

Shoulder

Appropriate for Physical Therapy and Further Work-

up/Additional Treatment

Not Appropriate for Physical

Therapy

Movement Impairment Scapula

Movement Impairment Gleno-humeral Joint

Consider Severity of -Irritability -Impairment

Gleno-humeral Joint

Hypermobility

Gleno-humeral Joint

Hypomobility Scapular Dyskinesis

Cervical Radiculopathy- Wainner

• ULTTA

• Involved Rot < 60 degrees

• Distraction

• Spurling’s A – 3/4 LR = +6.1; 4/4 LR= +30.9

– NCVT/EMG

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Shoulder Range of Motion- GH joint

Flexion

Abduction

External Rotation

Internal Rotation

Extension

What Are We Looking For: Full and painless

• Normal

Painful Arc

• Supra glenohumeral dysfunction.

Limited and painful

• Join dysfunction

• Supra glenohumeral dysfunction.

Limited and painless

• “Normal Stiffness”


Glenohumeral Instability1

Age: <40 y/o

History of trauma (dislocation, subluxation)

Participation in collision or overhead sports

Apprehension (Sn: 72%, Sp: 96%)1

Relocation (Sn: 81%, Sp: 92%)1

Sulcus (multidirectional) (Sn: %, Sp: %)3

Load and Shift (Sn: %, Sp: %)3


Adhesive Capsulitis1

History of diabetes or thyroid disorders

Severe loss of range of motion

Night pain

Pain felt in lateral deltoid

ROM loss in capsular pattern (ER, Abd, Flex)3

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Shoulder Range of Motion- Scapula Thoracic

Scaption/Elevation What Are We Looking For: Starting position

• Winging

• Scapular abduction

Movement patterns • Decreased upward scapular

rotation

• Anterior tipping of scapula (during shoulder elevation)

– Decreased serratus anterior activity

– Delays in lower and middle trap activation

– Enhanced upper extremity activity

• Decreases the subacromial Space.

https://www.youtube.com/watch?v=ROsiiDsjm2o


Shoulder Strength Testing

External Rotation Infraspinatus

Internal Rotation Subscapularis

Abduction Deltoid and Supraspinatus

Flexion Deltoid and Biceps long head.

Empty Can Supraspinatus

What are we looking for? Strong and Painless

• Normal

Strong and Painful

• Contractile element dysfunction.

Weak and Painful

• More Sever contractile element problem.

Weak and Painless • Neurological deficit

• Complete Rupture


Rotator Cuff Impingement/Tendonopathy1

Age: <40 y/o

Participation in overhead sports


Painful arc

Pain with overhead activities

Painful arc (Sn: 33% Sp: 81%)3

Loss of AROM (Sn: 30%, Sp: 78%)1

Hawkins-Kennedy (Sn: 72% Sp: 66%)1

Neer (Sn: 75% Sp: 48%)3

Pain to palpation of tendon insertion

https://www.youtube.com/watch?v=ROsiiDsjm2o

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Chronic Rotator Cuff Pathology/Tear1

Age: >40 y/o

Night pain


Pain with overhead activities ER MMT (infraspinatus) (Sn: 42%, Sp: 90%)1

Drop Arm Test (Sn: 27%, Sp: 73%)1

Empty Can (supraspinatus) (Sn: 44%, Sp: 90%)1

Lift Off (subscapularis) (Sn: 62%, Sp: 100%)1

Loss of AROM (Sn: 30%, Sp: 78%)1

ER Lag Sign (Sn: 70%, Sp: 100%)3


Clinical Decision Rule1

Rotator Cuff Tear

1. Empty Can

2. External Rotation Strength Testing

3. Impingement Signs

>98% tear with all 3 positive signs


Slides for Break-outs

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Hawkins' test for subacromial

impingement or rotator cuff

tendonitis. The arm is forward

elevated to 90 degrees, then

forcibly internally rotated.

Neer's test for impingement of

the rotator cuff tendons under

the coracoacromial arch. The

arm is fully pronated and placed

in forced flexion.

Supraspinatus examination ("empty can" test). The

patient attempts to elevate the arms against resistance

while the elbows are extended, the arms are abducted

and the thumbs are pointing downward.

Apprehension test for anterior instability. The

patient's arm is abducted to 90 degrees while

the examiner externally rotates the arm and

applies anterior pressure to the humerus.

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Sulcus test for glenohumeral instability.

Downward traction is applied to the

humerus, and the examiner watches for

a depression lateral or inferior to the

acromion.


References Part 1

1.http://www.bls.gov/news.release/osh2.nr0.htm

2.https://www.ncci.com/NCCIMain/Pages/Framework.aspx?articleUrl=/

3. Punnett L &Wegman DH.Work-related musculoskeletal disorders: the epidemiologic evidence and the debate. Journal of Electromyography and Kinesiology 2004; 14(1): 13–23.

4. National Research Council and the Institute of medicine. Musculoskeletal Disorders and the Workplace. Washington, D.C.: National Academy Press, 2001.

5. Punnett L & Herbert R.Work-related musculoskeletal disorders: is there a gender differential, and if so,what does it mean? Women and Health 2000; 38(6): 474–492.

6. Walker-Bone K, Palmer KT, Reading I & Cooper C. Soft-tissue rheumatic disorders of the neck and upper limb: prevalence and risk factors. Seminars in Arthritis and Rheumatism 2003; 33(3): 185–203.

7. Treaster DE & Burr D. Gender differences in prevalence of upper extremity musculoskeletal disorders. Ergonomics 2004; 47(5): 495–526.

8. Malchaire J, Cock N & Vergracht S. Review of the factors associated with musculoskeletal problems in

epidemiological studies. International Archives of Occupational and Environmental Health 2001; 74(2): 79–90.

9. van der Windt DA, Thomas E, Pope DP et al. Occupational risk factors for shoulder pain: a systematic

review. Occupational and Environmental Medicine 2000; 57(7): 433–442.

10. Ariens GA, van MechelenW, Bongers PM et al. Physical risk factors for neck pain. Scandinavian Journal of Work, Environment and Health 2000; 26(1): 7–19.

11. Ariens GA. Psychosocial risk factors for neck pain: a systematic review. American Journal of Industrial

Medicine 2001; 39(2): 180–193.


References Part 1

12. Croft P, Pope D, Silman A. The clinical course of shoulder pain: prospective cohort study in primary care. Primary Care Rheumatology Society Shoulder Study Group. Br Med J 1996;.

13. Hasvold T, Johnsen R. Headache and neck or shoulder pain- frequent and disabling conditions in the general population. Scandinavian Journal of Primary Health Care 1993; 11(3): 219–224.

14. Parsons S, Breen A, Foster NE, Letley L, Pincus T, Vogel S, et al. Prevalence and comparative troublesomeness by age of musculoskeletal pain in different body locations. Fam Pract, 2007. 24(4): p. 308–16.

15. Proper KI, Koning M, Van der Beek AJ et al. The effectiveness of worksite physical activity programs on physical activity, physical fitness, and health. Clinical Journal of Sport Medicine 2003; 13(2): 106–117.

16. Bergenudd H, Nilsson B. The prevalence of locomotor complaints in middle age and their relationship to health and socioeconomic factors. Clinical Orthopaedics and Related Research 1994, 308: 264–270.

17,Marcus M, Gerr F. Upper extremity musculoskeletal symptoms among female office workers: associations with video display terminal use and occupational psychosocial stressors. American Journal of Industrial Medicine 1996, 29: 161–170.

18. Leclerc A, Chastang JF, Niedhammer I, Landre MF, Roquelaure A. Incidence of shoulder pain in repetitive work. Occup Environ Med, 2004. 61(1): p. 39–44.

19. Bergenudd H, Lindgarde F, Nilsson B, Petersson CJ. Shoulder pain in middle age a study of prevalence and relation to occupational work load and sychosocial factors. Clinical Orthopaedics and Related Research 1987,231 234–237.

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References Part 1

20. Grooten WJ, Mulder M, Josephson M, Alfredsson L, Wiktorin C. The influence of work related exposures on the prognosis of neck/shoulder pain. Eur Spine J. 2007 Dec; 16(12):2083–91.

21. Devereux JJ, Vlachonikolis IG, Buckle PW. Epidemiological study to investigate potential interaction between physical and psychosocial factors at work that may increase the risk of symptoms of musculoskeletal disorder of the neck and upper limb. Occup Environ Med 2002; 59:269–277.

22. Pope DP, Croft PR, Pritchard CM, Silman AJ, Macfarlane GJ. Occupational factors related to shoulder pain and disability. Occup Environ Med 1997; 54:316–21.

23. Van der Heijden GJ. Shoulder disorders: a state-of-the-art review. Baillieres Best Pract Res Clin Rheumatol 1999; 13:287–309.

24. Larsson B, Sogaard K. Work related neck–shoulder pain: a review on magnitude, risk factors, biochemical characteristics, clinical picture and preventive interventions. Best Practice & Research Clinical Rheumatology 2007 Vol. 21, No. 3, pp. 447–463.

25. Leonard D. The effectiveness of intervention strategies used to educate clients about prevention of upper extremity cumulative trauma disorders. Work 2000; 14(2): 151–157.

26. Brewer S, Eerd DV, Amick III IB et al. Workplace interventions to prevent musculoskeletal and visual symptoms and disorders among computer users: a systematic review. Journal of Occupational Rehabilitation

2006; 16(3): 317–350.

27. Sjogren T, Nissinen KJ, Jarvenpaa SK et al. Effects of a workplace physical exercise intervention on the intensity of headache and neck and shoulder symptoms and upper extremity muscular strength of office workers: a cluster randomized controlled cross-over trial. Pain 2005; 116(1–2): 119–128.


References Part 2

1. Burbank, K, et al. Chronic Shoulder Pain: Part I Evaluation and Diagnosis. American Family Physician. 2008;77(4):453-460.

2. Goodman C, Snyder T. Differential Diagnosis for Physical Therapists, Chapter 18. St. Louis: Saunders Elsevier, 2007.

3. Cleland, J. Orthopaedic Clinic Examination: An Evidence-Based Approach for Physical Therapists, Chapter 10. Philadelphia: Saunders Elsevier, 2007.

4. Burbank, K, et al. Chronic Shoulder Pain: Part II Treatment. American Family Physician. 2008;77(4):493-498.

5. Lombardi I, et al. Progressive Resistance Training in Patients With Shoulder Impingement Syndrome: A Randomized Controlled Trial. Arthritis and Rheumatism. 2008; 59(5):615-622

6. 6. Tate, A, et al. Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial Impingement Syndrome: A Case Series. Journal of Orthopaedic and Sports Physical Therapy. 2010; 40(8):474-493

7. 7. Cummins, C, et al. Impingement Syndrome: temporal outcomes of nonoperative treatment. Journal of Shoulder and Elbow Surgery. 2009; 18: 172-177

8. 8. Haahr JP, etal. Exercisees versus arthoscopic decompression in patients with subacromial impingement: a randomised, controlled study in 90 cases with a one year follow up. Ann Rheum Dis. 2005; 64: 760-764.

occupational shoulder injuries - american college of ... · occupational shoulder injuries: a...

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