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