Effective Interventions for the Rehabilitation of Upper Extremity Cumulative Trauma Disorders

Laura Jones Chism, OTSSpalding UniversityJanuary 24, 2014

Practice Problem

Individuals with cumulative trauma disorders are at a greater risk for significant limitations in their ability to independently function within their home, jobs, and community. Many individuals present with debilitating symptoms such as pain, weakness, and swelling.

What are cumulative trauma disorders (CTDs)?

A cumulative trauma disorder is a condition where part of the body is injured by repeatedly overusing or causing trauma when the body part is called on to work harder, stretch farther, impact more directly or otherwise function at a greater level than it is prepared for.

*In 2012, CTDs accounted for 34% of all workplace injuries and illnesses requiring

absence from work.

Repetitive strain injuries

Work-related musculoskeletal

disordersOveruse syndrome

Risk factors for CTDs

• repetitive motions• forceful exertions• awkward postures• static postures• mechanical compression of soft tissues in the hand• fast movement of body parts• vibration, especially in cold conditions• lack of sufficient recovery time

How CTDs affect everyday occupational performance

•ADLs dressing, bathing, feeding

•IADLs cooking, caring for others, typing on the

computer, driving•Work

job performance•Leisure

hobbies such as sewing or playing golf

Level IIB Fieldwork experience

• VAMC in Lexington, KY*carpal tunnel syndrome (CTS)*lateral epicondylitis

• How are CTDs diagnosed?*patient symptom reports*provocative testing *EMG/Nerve conduction study *MRI *clinical exam (physician diagnoses)

Level IIB Fieldwork experience (continued)

• Treatments:*pre-fabricated splinting*retrograde massage*Fluidotherapy*tendon and nerve gliding exercises*patient education (activity modification, ergonomics)

*adaptive equipment for ADLs if needed

Research Process

Focus Question “What occupational therapy interventions are

effective in the rehabilitation of individuals with cumulative trauma disorders of the upper extremity?”

What interventions

reduce symptoms the

most?

What about DPAMs?

Do client-centered, tailored

therapies make a

difference?

Research Process

Database sources: AJOT, Medline, EBSCO

Articles within the past 5 years assessing: Exclusive interventions or combinations of the following: cryotherapy,

exercises, ultrasound*, neuromuscular electrical stimulation (NMES)*, tendon and nerve gliding exercises, Madenci Hand Massage Technique (MHMT), ischemic compression therapy

Diagnoses:Carpal tunnel syndrome and lateral epicondylitis

Outcome Measures assessing:Grip strength improvements, pain reduction, increased functional activities

*Deep Physical Agent Modality (DPAM)

What does the evidence say?

• Low-level frequency electrical stimulation used as a preparatory method for meaningful activities showed superior results for pain reduction, improved grip strength, and improved functional performance

One study concluded that 100% of participants maintained improved function and 83% remained pain-free for at least six months post treatment.

• The combination of tendon and nerve gliding exercises, ultrasound, and splinting resulted in significant improvements

The above treatment combination was significantly effective for up to 8 weeks after the treatment.

What does the evidence say?(continued)

• Ultrasound therapy showed significant improvements in functional performance scores, VAS pain levels, and grip strength

Pain at rest and in motion was significantly reduced following ultrasound therapy with carryover into 3 months post therapy

• Participants reported a preference toward certain therapies due to ease of use, effectiveness in symptom reduction, and overall comfort

• Clients with CTDs made strong, positive gains in functional measures following client-centered OT services

The COPM was the most sensitive to client change

Limitations of the studies

• Small treatment groups • Short term follow-up • Co-intervention bias was not always reported• Compliance in patient self-administered therapy• Subjectivity in patient questionnaire forms

Clinical bottom line

• Improved quality of life• Improved grip strength• Decreased pain• Improved performance and independence in

functional activities Return to work!

• Patients are likely to continue program

What does this mean for OT?

• Validates OT for treatment of UE CTD• Use DPAMs and conservative treatments as preparation

for or concurrently with purposeful and occupation-based activities that enhance engagement in occupation

Challenge: hand clinics typically treat with a more biomechanical approach using interventions such as paraffin bath, theraputty, etc

• Encourage client contribution in goal setting for improvements in meaningful ADLS/IADLS

• Choose tailored interventions based on the unique needs, preferences, and goals of patients

• AOTA Centennial Vision evidence based

Thank you!What questions do you have?

Laura Chism, OTSlaurajchism@gmail.co

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