neuromusculoskeletal disorders in the workplace
TRANSCRIPT
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Common neuromusculoskeletal
disorders in the workplace
W. Shane Journeay, PhD, MD, MPH, FRCPC, BC-OEM
OEMAC – Calgary
September 23, 2018
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OBJECTIVES
1. To name key diagnoses of neuromusculoskeletal conditions seen in the workplace
2. To describe the risk factors and mechanisms for common work-related neuromusculoskeletal conditions
3. To list key principles of management, rehabilitation and return to work in neuromusculoskeletal disorders
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Two common disorders
Shoulder
Spine
Other
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Approach and causality
Mechanism
Timeline of injury (Acute / chronic)
Type of occupation (dynamic, static postures)
Biomechanics
Medical history
Epidemiology
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Working towards a diagnosis
Bone - fracture, contusion
Muscle – strain, tear
Tendon – tendinosis/-opathy, tear
Bursa - bursitis
Ligament – sprain
Joint – arthritis
Nerve – entrapment, radiculopathy, PN
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Shoulder
History / Mechanism
Insidious onset vs Traumatic
Outstretch arm, pulling, reaching
Static postures
Exacerbating and relieving factors
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Examination
Posture
Active ROM
Passive ROM
Deformity
subluxed? A.C. deformity? Effusion?
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Subacromial Bursitis
Inflammation of bursa
Supraspinatus Tendinitis
Inflammation of tendon
Rotator Cuff Tears
Degenerative/traumatic
Impingement
One possible cause for pain
ROTATOR CUFF DISORDERS
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Supraspinatus
Empty Can test
“Jobe’s test”
Jain et al. PMR 2013
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Subscapularis
Belly Press off
Jain et al. PMR 2013
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Bicipital tendon
Speed’s Test
Jain et al. PMR 2013
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Impingement
Neer Sign
Jain et al. PMR 2013
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Management
Diagnosis?
Structure injured
Soft tissue?
Rest, ROM, Ice, NSAID
Investigation Ultrasound vs MRI
Rehabilitation
May require focused rehab depending on job tasks
Otherwise pain management and maintain ROM
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Question 1
A 50-year-old man sustains a left shoulder injury after falling from a ladder. A physical examination test to examine for this shoulder injury is found. What is the most likely diagnosis?
1. SLAP tear
2. Supraspinatus tear
3. Infraspinatus tear
4. Teres minor tear
5. Subscapularis tear
OrthoBullets
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Answer
A 50-year-old man sustains a left shoulder injury after falling from a motorcycle. A physical examination test to examine for this shoulder injury is found. What is the most likely diagnosis?
1. SLAP tear
2. Supraspinatus tear
3. Infraspinatus tear
4. Teres minor tear
5. Subscapularis tear
OrthoBullets
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Answer
Belly-press and Lift-off maneuvers
OrthoBullets
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Question 2 Rotator cuff tears (full thickness and partial thickness) in
asymptomatic individuals are seen on MRI or ultrasound
in what percentage of patients over the age of 60?
1. 0-5%
2. 5-30%
3. 30-55%
4. 55-80%
5. 80-100%
OrthoBullets
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Answer Rotator cuff tears (full thickness and partial thickness) in
asymptomatic individuals are seen on MRI or ultrasound
in what percentage of patients over the age of 60?
1. 0-5%
2. 5-30%
3. 30-55%
4. 55-80%
5. 80-100%
OrthoBullets
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Answer
The prevalence of asymptomatic rotator cuff tears
diagnosed with MRI or ultrasound is quite high, with most
studies noting tears in 30-54% of patients over the age of
60.
OrthoBullets
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Spine and Back pain
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Acute low back pain
Lumbar strain with or without radicular symptoms
Common
Lifting
New workers
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History
Red flags imaging
Medical history & Mechanism
Lifting
Twisting
Fall
Pain referral pattern (LBP +/- radicular symptoms)
Banding “Lumbago”
Radicular pain
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Red Flags
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Examination
Posture
Palpation/percussion -?Spasm
ROM
Neurological exam!
Bulk, Tone, Power, Reflexes, Sensation
Straight leg raise, Slump test, Femoral stretch
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Case 1
Hx: 54M construction worker presents with back pain
radiating down to the left ankle after lifting 75lb cement
blocks. Severe pain with onset x 24h. No hx of cancer,
diabetes. No history of neurogenic claudication. B/B
normal. Tried NSAIDs.
O/E: antalgic gait. Forward flexed. Can’t get
comfortable. SLR positive. 4+/5 left dorsiflexion.
MRI – posterolateral disc protrusion compressing exiting
L4 nerve root on left
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Lumbar Radiculopathy
Rule of thirds
1/3 traumatic events (I.e.heavy lifting)
1/3 routine activity (walking, making bed)
1/3 non-specific (I.e. arising from chair, at rest)
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Lumbar disc herniation
Deyo & Mirza NEJM 2016
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Common Lumbar Dermatomes
Deyo & Mirza NEJM 2016
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Gluteus medius & Longissismus (can mimic
radiculopathy)
Triggerpoints.net “pseudo-sciatica”
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Management & Rehabilitation
Monitor + Conservative modalities
Counsel on recovery and red flags
If persistent pain, loss of motor function obtain
imaging, or red flags
Regular activity +/- PT
Epidural – If completed early can improve pain sooner
but after 6-12 months everyone is the same
Ergonomics
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Case 2
Hx: 25M with back pain since age 21. Began working for moving company and ‘flared’ his pain. Pain is located in left low back, “deep”. No radicular pain. No B/B dysfunction. No leg weakness. No red flags. No sensory changes. <30 mins of morning stiffness. Better with light activity. Worse with long day of work or heavy work out. No stigmata of rheumatological disease. His FHx is non-contributory. Did report “wrenching his low back” diving at age 21.
O/E: Neuro intact. Full flexion and extension. Lateral bending to the right can only reach 3 cm proximal to fibular head and the left can reach fibular head. Point tenderness over left quadratus lumborum that reproduced his pain.
X-ray and SI joint views- normal. HLA B27 negative. Inflammatory markers normal.
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Myofascial pain / Lumbar strain
Myofascial low back pain: may have trigger points include the
iliocostalis lumborum, longissimus thoracis, multifidus,the
quadratus lumborum and gluteus medius are the most frequently
involved
Triggerpoints.net
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Role of Electrodiagnostics (EMG/NCS)
Localizes peripheral nerve lesions
Tests the integrity of the motor units and sensory nerves
Can determine neurophysiology of multiple nerves or
myotomes and chronicity
Does not say ‘what’ is causing the problem
Often concludes – “Suggest MRI of L/S spine “
With good physical exam and MRI; little role for EDx
Caveats - neurorecovery and surgical planning
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Summary
Shoulder injuries are common with the majority comprising soft-
tissue injury. Careful history and exam can narrow the differential
and guide management
Management is generally conservative
Back pain is not always simple back pain - Neurology and
function are a priority
Many rehabilitation strategies – ranging from pain management,
exercise and focused rehabilitation strategies
Questions & Discussion?
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References
Jain et al. PM&R 5:45-56, 2013
Deyo & Mirza NEJM 374:1763-72, 2016
Carette & Fehlings NEJM 353:4, 392-99, 2005
Orthobullets
Triggerpoints.net