common msk injuries and outcomes drs lacerte and orner · treatments options: non-surgical...

Common MSK Injuries and Outcomes

April 27, 2018

Dr. Michel LacerteDr. Avi Orner

1. Overview of MSK Injuries and Fractures

2. Whiplash and Low Back Pain

3. Chronic Stress‐related Workplace Injuries

4. Overview of OPTIMa

WHO/AMA GUIDES DEFINITIONS OVERVIEW 

Disease/Illness

Impairment 

Disability

Handicap

COMMON TERMS

Impairment

• “In the context of health experience, an impairment is any loss or abnormality of psychological, physiological, or anatomical structure or function”

Disability• “In the context of health experience, a disability is any restriction or lack

(resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being

Handicap• “In the context of health experience, a handicap is a disadvantage for a given

individual, resulting from an impairment or a disability, that limits or prevents the fulfilment of a role that is normal (depending on age, sex, and social and cultural factors) for that individual

An impaired individual who is able to accomplish a specific task with or without accommodation is neither handicapped nor disabled with regard to that task.

Circumstances/Causation

Impairment

Restrictions

Action/Activities

THE IME PATHWAY

COMMON MEDICAL TERMS

•Acute– The phase of healing which occurs immediately after an injury (2-

4 weeks for STI’s

•Sub-Acute

– Phase of an injury during which healing may still be in process, but without acute symptomatology (pain, inflammation, tenderness)

•Chronic

– Injuries, disabilities and/or conditions which last longer than the usual healing time

•Sign– A finding noted by a HCP on physical examination

•Symptom

– A patient generated complaint or statement

COMMON MEDICAL TERMS

Distal

Parts of the limbs away from the body or midline

Proximal

Parts of the limbs closer to the body or midline

Peripheral and Central Nervous/Vascular Systems

Cervical

Anything pertaining to the neck

vs. thoracic, lumbar, sacral

ANATOMICAL PLANES

COMMON MEDICAL TERMS

Contusion

A bodily injury without a skin break

Bruise

Sprain

The tearing of a ligament that occurs when a joint is forced beyond its normal range of motion

Ligaments join bone to bone

Strain

When muscle or tendon is torn or over-stretched

Tendons join muscle to bone

SUFFIXES AND PREFIXES

• ‐itis = inflammation

• myo = pertaining to muscle

• dys = indicates an abnormality

• a- or an- = indicates an absence

• osteo = pertaining to bone

• DDD = degenerative disc disease

• ectomy = surgical removal or excision

• otomy = surgical creation of an opening

SUFFIXES AND PREFIXES

• -oscopy = internal fibre optic viewing

• arthro = pertaining to joints

• -algesia = pertaining to pain

• costo = refers to the ribs

• chondro = refers to cartilage

INJURY TO MSK SYSTEM

• Soft tissues

Ligaments

Tendons

Muscles

• Bones

• Joints

Cartilage

o Pre-existing degeneration

• Whiplash

SOFT TISSUE IMPAIRMENTS

•Bursitis

– Inflammation of a bursa

– Sacs of fluid between bone, skin, and tendons

• Tendinitis

– Inflammation of a tendon

– Typically near bony insertion sites

•Laceration

– A cut or breaking of the skin

– Location, size, depth, associated underlying structures, condition of surrounding tissue

TENDINITIS

TreatmentElimination of repetitive task until full recovery

Physical therapy

Stretches and Exercises

Medical treatment

Anti-inflammatory pills or injections

Outcome Variable; usually months for chronic

problems

TENDON RUPTURE

Supraspinatous

Infraspinatous

Teres Minor

Subscapularis

•Degree

–Partial

–Complete

TREATMENT OF TENDON TEARS

Partial Usually non-surgical

Modification of ADL and employment

Rehabilitation, medications/injections

Outcome ranges from complete recovery to some persistent symptoms

Complete Most often require surgical repair

Loss of function can be significant

SOFT TISSUE HEALING AND INFLAMMATION

A System of Orthopaedic Medicine, 2nd Edition. Ombregt L et al (2003)

Soft Tissue Healing – Effects of Mobilization

Tissue Immobilization Mobilization

Joint capsule 1. Distribution of blood and lymph flow 2. Intense synovitis 3. Loss of extracellular water and GAG content 4. Deposition of excessive connective tissue 5. Decreased collagen mobility 6. Intra‐articular adhesions 7. Laxity and destruction of ligament insertion site

1. Increased circulation 2. Prevention of abnormal adhesions 3. Beneficial influence on the remodeling process 4. Increase of strength of connective tissue in 

ligaments 

Synovial fluid Alteration of viscoelastic properties 

1. Increase of compression 2. Deposit of end‐products of metabolism 3. Decrease of elastic properties 4. Autolysis of cartilage 

1. Beneficial effect on assimilation of nutrients 

Cartilage Muscles 1. Atrophy 2. Decrease of strength3. Increase of amount of connective tissue4. Disturbance of neuromuscular coordination of 

muscle groups 

1. Increased circulation 2. Increase of muscle strength and endurance 3. Maintenance of proprioceptive reflexes which 

ensure active joint stability 

A System of Orthopaedic Medicine, 2nd Edition. Ombregt L et al (2003)

PUTTING IT ALL TOGETHER –SPINS, SNOUTS AND EBM

A B

C D

Test positive

DiseaseAbsent

Disease present

Test negative

A = True positiveB = False positiveC = False negativeD = True negative 

Sensitivity = A/[A+C]Specificity = D/[B+D]PPV = A/[A+B]NPV = D/[C+D]

SHOULDER PAIN ≠ RC TEAR

Source: UpToDate 2013

SHOULDER DIAGNOSTICS (ACR)

RATINGS: 1,2,3 – not appropriate 4,5,6‐may be appropriate 7,8,9 – usually appropriate

Source: UpToDate 2013

DIAGNOSING RC CONDITIONS

U/S: Sensitive test to r/o rotator cuff tear (especially full thickness) and shoulder impingement.

Operator dependent – specialized training required. Should be incorporated with ‘dynamic’ physical exam

Less sensitive for partial RC tears compared with MRI

Decreased accuracy in very small or large tears (>3 mm)

Limited usefulness with bony lesions

Low sensitivity for shoulder instability or labral tears

MRI: Useful for definitive diagnosis of RC, tendons, bursa and biceps

Preoperative planning

Subtle fractures, erosive clavicle changes, AC joint changes acromion morphology and muscle atrophy

Second choice for labral tear if MR arthrography not performed

Interpretation may vary by experts – need clinical/radiological collaboration

54% of asymptomatic patients >60 yrs. had signs of rotator cuff tear on MRI

Source: UpToDate 2013

OUTCOME OF TENDON RUPTURES

Goal of treatment Return to full function

Prolonged rehabilitation 3 to 6 months

Lifelong increase in the risk of re-rupture

LIGAMENT INJURIES

ACL Tears:• Grade 1 Sprains. Ligament is 

mildly damaged and has been slightly stretched, but is still able to help keep the knee joint stable.

• Grade 2 Sprains. Stretches the ligament to the point where it becomes loose. 

Partial tear (rare) 

• Grade 3 Sprains. Ligament has been split into two pieces, and the knee joint is unstable.

Complete tear

Treatment of Ligamentous Lesions

Phase Treatment (1) Treatment (2)

First Day Following Days First Day Following Days

Acute Phase

Joints controlled by Muscles

Compressionelevation

Effleurage+Deep transverse massageControlled movements (active and passive)Gait instruction

Alternative (within 48 hours)Steroid infiltration

Controlled movements (active and passive)Gait instruction

Joints not controlled by Muscles

Deep transverse massageImmobilization

Infiltration (steroid or sclerosant)Immobilization

Chronic Phase

Adhesive scar formation

Deep transverse friction +Manipulation

(Steroid infiltration)

Lastinginstability

Strength‐building exercisesPropioceptive training

Surgical reconstruction(infiltration with sclerosant)

A System of Orthopaedic Medicine, 2nd Edition. Ombregt L et al (2003)

TREATMENT OF LIGAMENT RUPTURES

Non-surgical treatment

Period of immobilization

Bracing

Rehabilitation

Indications

All partial tears

Some complete tears (depending on age/activity level)

Ankle collateral ligament

Knee collateral ligament

Rehabilitation of 3 to 12 weeks

SURGICAL TREATMENT OF LIGAMENT INJURIES

• Usual recovery from ACL reconstruction with rehabilitation is about 6-9 months

• Nearly normal function is expected

SUMMARY OF LIGAMENT INJURIES

Most partial tears will heal with non‐surgical methods

Surgery is indicated for select complete tears

Rehabilitation can take from a few weeks for partial tears to many months following surgical reconstructions

BONE AND JOINT IMPAIRMENTS

Fractures A break in a bone closed vs open displaced, angulated, rotated, comminuted, intra-articular callus, healed, non-union, mal-union

Dislocations When the articular surface of a bone is not in the joint

space proper Anterior, posterior, medial, lateral May or may not have a fracture associated with it

Bone and Joint Impairments

Arthritis

Inflammation of a joint

Congenital vs acquired

Underlying wear and tear

Degenerative Disc Disease (DDD)

Condition of the spine (cervical, thoracic or lumbar) which is associated with the normal aging process

Wear and tear of the spinal joints

FRACTURES - DEFINITION

• Force applied

• Continuity of bone structure is disrupted

• Diagnosis

X-ray

CT scan

Bone scan

MRI

HEALING OF FRACTURES

• Bone regenerates with bone

• Callous formation takes time

• Treatments are aimed at allowing the body to heal itself

METHODS OF FRACTURE TREATMENT

Immobilization of the fractured bone

Closed

• Cast

• External fixator

Open

• Nails

• Plates and/or screws

Prevention of secondary problems

• Stiffness of nearby joints

• Atrophy and weakness of muscles

METHODS OF FRACTURE TREATMENT

METHODS OF FRACTURE TREATMENT

OUTCOME OF FRACTURES

Healing times – Union and Rehabilitation Union

Vast majority will unite over some period of time

The closer to the anatomical position the better the outcome

Rehabilitation

Length to union

o Degree of secondary changes

o Bone quality, smoking

Associated injuries (soft tissues)

ER DIAGNOSTIC DECISIONS: FOOT AND ANKLE INJURIES

Ankle X‐rays if (one of):•Bone tenderness at A•Bone tenderness at B•Inability to weight bear immediately and in the ED

Foot X‐rays if (one of)•Bone tenderness at C•Bone tenderness at D•Inability to weight bear immediately and in the ED

ANKLE JOINT ANATOMY AND RADIOLOGY

ANKLE FRACTURES

Treatments Options: Non-surgical (decreased bone stability, malunion etc.) vs. Surgical (risks include bone healing, arthritis, pain from hardware + general surgical risks)

Recovery: Wide range of how people heal after their injury - at least 6 weeks for the bones to heal, longer for the involved ligaments and tendons

Pain management: Options include opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics.

Rehabilitation: Physical therapy, home exercise programs, weightbearing tolerance, strengthening exercises etc.

Supports: Splint initially then cast, removable brace

Complications: Smokers, diabetes or elderly. Non-union, malunion and wound healing issues

KNEE OSTEOARTHRITIS

Degenerative, "wear-and-tear“ - most common form of arthritis in the knee

Most often in people 50 years of age and older, but may occur in younger people as well

Cartilage in the knee joint gradually wears away - becomes frayed and rough, and the protective space between the bones decreases.

Can result in bone rubbing on bone, and produce painful bone spurs.

OA develops slowly and the pain it causes worsens over time.

KNEE OSTEOARTHRITIS: SYMPTOMS

• Pain and inflammation – develops gradually over time, although sudden onset also possible or with vigorous activity.

• Other symptoms:

Joint may become stiff and swollen, making it difficult to bend and straighten the knee.

Pain and swelling - worse in the morning, or after sitting or resting.

Knee may "lock" or "stick" during movement – due to loose fragments of cartilage and other tissue

Knee may creak, click, snap or make a grinding noise (crepitus).

Sensation of weakness or buckling in the knee due to pain.

Increased joint pain with rainy weather can be reported.

KNEE OSTEOARTHRITIS: TREATMENT

Nonsurgical

• Lifestyle modifications.

• Physical therapy, assistive devices

• Heat, ice, ointments, creams, or elastic support bandages

• Medications:

OTC, non-narcotic pain relievers and anti-inflammatory medications

NSAID, COX-2 Inhibitors

Corticosteroids injections

Viscosupplementation

• Dietary supplements

• Alternative therapies – Acupuncture, magnetic pulse therapy etc.

Surgical

Arthroscopy

Cartilage grafting

Synovectomy

Osteotomy

Total or partial knee replacement (arthroplasty)

POSTTRAUMATIC AND RHEUMATOID ARTHRITIS

Posttraumatic Arthritis

Form of arthritis that develops after an injury to the knee (fracture may damage the joint surface and lead to arthritis years after the injury)

Meniscal tears and ligament injuries can cause instability and additional wear on the knee joint, which over time can result in arthritis

Damage is irreversible - cartilage does not regenerate

Degree of the damage determines long-term outcome

Rheumatoid Arthritis Symmetrical chronic disease that attacks multiple joints throughout the body,

including the knee joint

Synovial membrane begins to swell - pain and stiffness

Autoimmune disease - immune system damages normal tissue (such as cartilage and ligaments) and softens the bone

1. Overview of MSK Injuries and Fractures

2. Whiplash and Low Back Pain

3. Chronic Stress‐related Workplace Injuries

4. Overview of OPTIMa

ANATOMY OF THE SPINE

CERVICAL SPINE: ANATOMY

https://orthoinfo.aaos.org/en/diseases‐‐conditions/cervical‐radiculopathy‐pinched‐nerve/

CERVICAL SPINE: RADIOLOGY

MVA 18 year old male. C6/7 fracture dislocation with cord contusion and bilateral jumped facet 

joints (radiopaedia.org).

www.orthobullets.com

CERVICAL SPINE PAIN ANALYSIS

A System of Orthopaedic Medicine, 2nd Edition. Ombregt L et al (2003)

CERVICAL SPINE: ADVANCED IMAGING

• Hyperflexion injury in a 17‐year‐old boy involved in a motorcycle crash.

• Right vertebral artery injury and bilateral C4‐5 facet fracture‐subluxation

Radiology: Volume 263: Number 3—June 2012

MUSCULOSKELETAL SYMPTOMS

Pain

Neck

Surrounding regions

oHead

oShoulders and arms

oUpper back

Stiffness

Muscle spasms

WHIPLASH ASSOCIATED DISORDERWAD I/II

• Persistent neck pain as a result of acceleration-deceleration (hyper extension/flexion) force applied to the neck

• No other bone or joint injuriesFractureDislocationDisk herniation

SYMPTOMS (CONT….)

Neurological

Numbness and/or tingling

Dizziness and vertigo

Headaches

WAD SIGNS

MSK

Tenderness

Decreased range of motion

Neck pain on mobilization

Neurological (from neck)

Decreased or altered sensation

Decreased strength

Altered reflexes

TREATMENT

No standard, widely accepted treatment (see OPTIMa)

Most will recover without any specific interventions beyond simple measures

Short rest

Simple over the counter pain killers

Prompt return to all pre-injury activities

QUEBEC TASK FORCE STUDY: Predictors of Outcome

Population

All MVA victims who submitted a claim in 1987

2627 subjects were studied

Avg. age 37

64% female

58% working full time

RECOVERY

Median (50%) recovery was 32 days

12% still not recovered after 6 months

CLASSIFICATION

WAD I (66%)

Complaints of pain and/or stiffness without physical signs

WAD II (29%)

As above with MSK signs (tenderness, loss of ROM)

WAD III (5%)

As WAD II with neurological symptoms and signs

RECOVERY (CONT…..)

RECOVERY

Median recovery time

WAD I 25 days

WAD II 54 days

WAD III 76 days

At 1 year after injury still not recovered

1.4% WAD I

1.8% WAD II

4.8% WAD III

PREDICTORS OF POOR OUTCOME

Accident‐related

Additional injuries

Being involved in a severe crush

Vehicle other than car or taxi

Not wearing a seatbelt

Socio‐economic

Female gender

Older age

Greater number of dependents

PROGNOSTIC FACTORS

Prolonged recovery

Old age and female gender

Baseline neck pain and headache

Neurological signs and symptoms

Mechanism of the accident in question

WHIPLASH SUMMARY

Favorable prognosis in majority of cases

In most cases no specific interventions are required beyond simple pain treatment and a prompt return to normal activities

Small proportion end up with chronic pain

Older female

Severe initial intensity of pain

Presence of neurological signs and symptoms

Source: UpToDate 2013

MANAGEMENT OF ACUTE LOW BACK PAIN

MRI VS. X-RAYS AS INITIAL IMAGING FOR LBP

MRI provides reassuring information for both patients and physicians.

Does not appear to cause harm or greatly increases costs (overall)

Symptoms and functional outcomes are not, on average, improved

Potential to increase the number of back operations without an apparent benefit. 

“…  a cautious approach is probably most prudent, and we recommend that rapid MRI not become the first imaging test for primary 

care patients with back pain until its consequences for surgical rates and costs are 

better defined.”

Rapid Magnetic Resonance Imaging vs Radiographs for Patients With Low Back Pain:

A Randomized Controlled TrialJAMA. 2003;289(21):2810-2818. doi:10.1001/jama.289.21.2810

LUMBAR SPINE – X-RAY IMAGING

LUMBAR SPINE PATHOLOGY

Source: Harrison’s Principles of Internal Medicine, 17th Edition

Dx: Herniated L5‐S1 disk; left S1 radiculopathy Dx: Multifocal spinal stenosis; compression of CSF

LUMBAR SPINE: ADVANCED IMAGING

LUMBAR SPINE: PATHOLOGY

Axial CT of lumbar spine burst injury – mechanism of injury (emedicine) 

LUMBAR SPINE: ADVANCED IMAGING

Three‐dimensional CT colour‐coded angiogram. (Bone Joint J August 2005 vol. 87‐B no. 8 1029‐1037)

3D reconstruction of a CT scan – L1 vertebral body compression and rotation under T12, with severe neurologic injury to the conus 

and cauda equina. 

LUMBAR SPINE: LOOKING AHEAD

3D CT and  fusion with 18F scan showing readily identifiable correlation of vertebral bodies and areas of disease, including localization of compression fractures and facet disease in a case of new‐onset back pain with numerous compression fractures 

and kyphoplasties. J Nucl Med Technol. 2007 Sep;35(3):147

LUMBAR SPINE: LOOKING AHEAD

18F‐FDG PET and companion 18F bone scan of metastatic disease of lumbar vertebrae J Nucl Med Technol. 2007 Sep;35(3):147

1. Overview of MSK Injuries and Fractures

2. Whiplash and Low Back Pain

3. Chronic Stress‐related Workplace Injuries

4. Overview of OPTIMa

CHRONIC STRESS‐RELATED WORKPLACE INJURIES

1. Stress: Definition and impact

2. Biopsychosocial models of stress effects 

3. Clinical consequences of stress – metabolic and mechanical

STRESS OVERVIEW

• Stress occurs when you have to handle more than you are used to

• When you are stressed, your body responds as though you are in danger

Hormones are produced that speed up your heart, make you breathe faster, and give you a burst of energy

The fight-or-flight stress response

• Some stress is normal and even useful (need to work hard or react quickly)

LIFE STRESS INVENTORY (HOLMES AND RAHE)

Death of Spouse 100Divorce 73Jail term 63Death of close family member 63Marriage 50Fired at work 47Retirement 47

Gain of a new family member 39Large mortgage or loan 31Trouble with boss 23Change in residence 20Vacation 13Christmas 12Minor violations of law 11

Holmes, TH & Rahe, RH, J Psychosomatic Research 11: 213‐218, 1967http://www.mindtools.com/pages/article/newTCS_82.htm

STRESS AND ILLNESS IN PRIMARY CARE PRACTICE

Review of audiotapes of primary care practice of patients with ‘chronic-disease’

439 interactions with 49 physicians

Stress was by far the most time consuming topic.

Nearly 60% of the discussions were attempts to counsel or encourage behavior change in the patient

Estimated that 70-80% of primary care visits involve an illness that is caused or augmented by stress

Russell & Roter (1993) Am J Public Health 1993; 83: 979‐982

WORK-RELATED STRESS AND ILLNESS

10,308 civil servants in the UK

Work stress = poor work social support, high job demands, and low job control

Associated with increased risk of BMI obesity (odds ratio, 1.73), and waist obesity (odds ratio,1.61)

Men were more likely than women to suffer the negative effects of job strain in terms of obesity

Women did not experience a significant increase in waist obesity with stress.

Brunner et al. (2007) Am J Epidemiol 165:828‐837

Stress: Acute vs. Chronic

Acute (short‐term) stress:

The body's instant response to any situation that seems demanding or dangerous. 

Stress level depends on how intense the stress is, how long it lasts, and how one copes with the situation

The body normally recovers quickly from acute stress

Problems occur if it happens too often or if the body doesn't have a chance to recover 

In individuals with cardiac conditions, acute stress can trigger an arrhythmia or heart attack.

Chronic (long‐term) stress:

Caused by stressful situations or events that last over a long period of time 

Examples include a difficult job or dealing with a chronic disease 

Any pre‐existing health issues can be made worse with stress

CHRONIC STRESS‐RELATED WORKPLACE INJURIES

1. Stress: Definition and impact

2. Biopsychosocial models of stress effects 

3. Clinical consequences of stress – metabolic and mechanical

THE STRESS RESPONSE

http://www.health.harvard.edu/newsletters/Harvard_Mental_Health_Letter/2011/March/understanding‐the‐stress‐response 

Stressful event

Amygdala

Hypothalamus

Fight or flight

NERVOUS SYSTEM OVERVIEW

NEURORECEPTORS OF PAIN

Stahl, Stephen M. "Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical Applications”. Figure 10-6

DSM-5: SYMPTOMS OF SSD

A. One or more somatic symptoms that are distressing or result in significant disruption

B. Excessive thoughts, feeling or behaviours related to somatic symptoms or associated health concerns

Disproportionate and persistent thoughts about the seriousness of symptoms

Persistently high level of anxiety about health/symptoms

Excessive time and energy devoted to these symptoms/health concerns

A. The state of being symptomatic is persistent

Subtypes:

With predominant pain, persistent, severity (mild/moderate/severe)

ALLOSTATIC LOAD

McEwen (1998) N Engl J Med 338:171‐179

ALLOSTATIC LOAD

Perception of stress is influenced by one's experiences, genetics, and behavior.

Model transcends any one organ system

When the brain perceives stress, physiologic and behavioral responses are initiated leading to allostasis and adaptation.

Over time, allostatic load can accumulate, and the overexposure to neural, endocrine, and immune stress mediators can have adverse effects on various organ systems

The model provides a basis for understanding connections among the etiology of systemic illnesses such as CVD and mental illnesses such as depression and the condition of hostility.

McEwen BS (2004) Allostasis and allostatic overload and relevance to the pathophysiology of psychiatric disorders. Annals of the New York Academy of Sciences 1032, 1–7. 

ALLOSTATIC OVERLOAD: WEAR AND TEAR ON THE BODY DUE TO CHRONIC STRESS

Decreased immune functions

Hypertension

Atherosclerosis

Increase platelet reactivity

Abdominal obesity

Bone demineralization

Atrophy of neurons in hippocampus and prefrontal cortex

Increased activity of amygdala

OCCUPATIONAL PERFORMANCE MODEL

89

As it applies to the Work Assessment Continuum

THE STRESS RESPONSE: ABILITY AND DEMANDS

Goleman (2006) Social Intelligence, the new science of human relationships, Random Househttp://drmichellecleere.com/2012/mental‐moment‐is‐all‐stress‐bad 

CHRONIC STRESS‐RELATED WORKPLACE INJURIES

1. Stress: Definition and impact

2. Biopsychosocial models of stress effects 

3. Clinical consequences of stress – metabolic and mechanical

STRESS EFFECTS

Stress

Metabolic Effects

Cardiovascular

Immune

Gastrointestinal

Mental Health

Musculoskeletal

Mechanical Effects

Work‐related musculoskeletal 

disorders 

STRESS: COMMON SYMPTOMS (ACUTE)

Fast heartbeat (tachycardia)

Headache

Stiff neck and/or tight shoulders

Back pain

Fast breathing

Sweating, and sweaty palms

Upset stomach, nausea, or diarrhea

STRESS: COMMON SYMPTOMS (CHRONIC)

Immune system

More likely to get sick more often

May aggravate existing chronic illnesses such as AIDS, cancer etc.

Cardiovascular

Linked to high blood pressure, abnormal heartbeat (arrhythmia), blood clots, and hardening of the arteries (atherosclerosis)

Stress is also linked to coronary artery disease, heart attack, and heart failure

Muscular

Constant tension from stress can lead to neck, shoulder, and low back pain

Stress may make rheumatoid arthritis worse

STRESS: COMMON SYMPTOMS (CHRONIC)

Gastrointestinal

May aggravate conditions such as gastroesophageal reflux disease (GERD), peptic ulcer disease, or irritable bowel syndrome

Reproductive organs

Low fertility, erection problems, problems during pregnancy, and painful menstrual periods.

Respiratory

Stress can exacerbate symptoms of asthma and chronic obstructive pulmonary disease (COPD)

Skin

Conditions such as acne and psoriasis are made worse by stress

Psychiatric

An extreme reaction to stress is a panic attack

PTSD, depression and other anxiety disorders

PHYSIOLOGIC EFFECTS OF STRESS ON THE MSK SYSTEM

Physiological change How MSK Risk is Increased

↑ blood pressure ↑ pressure in the joint specifically on tendons, ligaments, and nerves (carpal tunnel)

↑ fluid pressure ↑ pressure may be placed in joints, and on tendons, ligaments, and nerves.

↓ Growth func ons ↓ Collagen means ↓ ability for the body to heal or recover after performing work functions

↓ Sensi vity to pain workers may work beyond and above their body’s physical capacity

Dilation of pupils ↑ Increased sensi vity to light

↑ Muscle tension ↑ pressure on and around joints, tendons, ligaments, nerves, and may cause excessive use of force during certain activities and movements

Body remains at a heightened state of sensitivity

Worker may overburden their musculoskeletal system (lift more, work faster, etc.

http://www.ccohs.ca/oshanswers/psychosocial/musculoskeletal.html

Work Related Musculoskeletal Disorders (WMSD’s)

Many Alternate Names:

• Repetitive motion injuries

• Repetitive strain injuries

• Cumulative trauma disorders.

• Occupational cervicobrachial disorders

• Overuse syndrome

• Regional musculoskeletal disorders

• Soft tissue disorders

WORK RELATED MUSCULOSKELETAL DISORDERS (WMSD’S)

Normal motions (bending, straightening, gripping etc.) can become hazardous in the workplace with:

• Continual repetition

• Forceful manner of motion

• The speed of the movements 

• The lack of time for recovery between movements

Risk Factors:

• Fixed or constrained body positions

• Continual repetition of movements

• Force concentrated on small parts of the body, such as the hand or wrist

• A pace of work that does not allow sufficient recovery between movements

A combination of any of the above factors is the most common scenario

WORK RELATED MUSCULOSKELETAL DISORDERS (WMSD’S)

1. Muscle injury

Muscle contraction that lasts a long time reduces the blood flow

Accumulation of waste materials causes pain with prolonged time of contraction

WORK RELATED MUSCULOSKELETAL DISORDERS (WMSD’S)

2. Tendon injurya. With sheaths Inadequate lubrication

system leads to inflammation, fibrous tissue formation and decreased ROM

b. Without sheaths Tensing of tendon leads to

tears, inflammation of both tendon (tendonitis) and bursa (bursitis)

WORK RELATED MUSCULOSKELETAL DISORDERS (WMSD’S)

3. Nerve injury With repetitive motions and 

awkward postures, the tissues surrounding nerves become swollen, and squeeze or compress nerves 

Compression of a nerve causes muscle weakness, sensations of "pins and needles" and numbness. Dryness of skin, and poor circulation to the extremities, may also occur

WMSD’S: SYMPTOMS

Early stage Aching and tiredness of the affected limb occur during the work shift

Symptoms disappear at night and during days off work

No reduction of work performance. 

Intermediate stage Aching and tiredness occur early in the work shift and persist at night 

Reduced capacity for repetitive work

Late stage Aching, fatigue, and weakness persist at rest

Inability to sleep and to perform light duties 

WMSD’S: TREATMENT

A. Restriction of movement Often requires work restrictions or transfer to different job Splints should not be used for mechanical support in an occupational 

setting, rather redesign job to minimize load on the jointB. Application of heat or cold Relieve pain and may accelerate the repair process Cold reduces pain and swelling and is recommended for injuries and 

inflammations  Ice is not recommended in case of muscle pain (spasm) ‐ only 

immediately after an injury occurred, and only for few days.  Heat for muscle pain relief, not for injuries with significant inflammation 

and swellingC. Exercise Stretching promotes circulation and reduces muscle tension

D. Medication and surgery

JOB STRESS: SIGNS

Headaches

Trouble sleeping

Problems concentrating

Short temper

Upset stomach

Job dissatisfaction and low morale

JOB STRESS: CAUSES

Lack of control

Increased responsibility

Job satisfaction and performance

Uncertainty about work roles

Poor communication

Lack of support

Unpleasant or dangerous physical conditions, such as crowding, noise, or ergonomic problems

THANK-YOU