Clinical Bibliography
This is my “bibliography of clinical practice and philosophy”. Evidence based medicine is good practice and a sound way to do business. Nothing that I do clinically is “made up” or “invented” by myself or the mentors I have chosen to work with over the years. Much of the material contained comes directly from, or is adapted from the website of my last clinical instructor while a student, my mentor, and my first employer upon graduation, Lauren Hebert. His website can be found at https://www.smartcarept.com/smartcare/Home.html.
I know Lauren would be happy to have you visit his website and browse through what he has assembled over the years for information about how we help you to help yourself. Lauren is an “Orthopedic Certified Specialist” through the American Physical Therapy Associations Board of Certified Specialists, and has over 35 years experience as a physical therapist. He earned my respect and admiration while I studied with him as a student, and continued to do so while I worked with him as a mentor and a peer. We continue to be close friends and associates, and I will always look to him for a recommendation when I become stuck, which continues to happen occasionally despite my experience so far.
I began studying to be a physical therapist in 1995, after applying to two programs and being accepted into the MSPT program at Husson College, in Bangor, Maine. Prior to returning to school I worked in law enforcement, private security, firefighting/EMS, and various part time jobs in retail and construction. As a teenager I was involved in football and wrestling in school, and lifted weights and studied martial arts. Over the years I have come to appreciate the human body’s amazing ability to simply heal and adapt to stresses, with appropriate nutrition, rest, and loading. Simply put, used properly and maintained, the human body is capable of adapting to and sustaining stresses that would destroy anything created by man inside of a very short period of time. I’d be remiss if I did not include, somewhere in my personal bibliography some mention of God. He gets the credit, if only mentioned rarely and when the subject is brought up by a patient. It was Him who allowed me the opportunity to be born into the family I was, and to grow into the person I am.
Following is a listing, with a few “excerpts” cited, of clinically relevant peer reviewed articles from which I have drawn knowledge and information to better serve my patients’ needs. The resources listed here were used directly in the development of the “Clinical Protocols” posted to this website.
(Check back frequently as these pages will be updated regularly with additional evidence to reinforce what we do clinically.)
KEY
EX – Related to the use of exercise in physical therapy
US - Related to efficacy of Ultrasound related modalities in physical therapy
LS – Related to efficacy and use of laser energy in therapy.
MT – Related to efficacy and use of manual therapy and traction in therapy.
*** - Related to workplace stretching articles
^^^ - Related to posture as MSD risk
BIBLIOGRPAPHY
^^Bullock, M., ed.: ERGONOMICS: THE PHYSIOTHERAPIST IN THE WORKPLACE,
Churchill-Livingstone, 1991.
This landmark text describes the role of the physical therapist as the most
qualified industry resource for ergonomics. The physical therapist is described
as providing a valuable mix of musculoskeletal medical training with human
biomechanics and physics of movement and posture as the basic science foundation
of this profession. Most large industry settings in Europe employ on-site
physical therapists as their ergonomics resource (in contrast with US industry
which relies primarily on engineers.) In Scandinavian countries ergonomics is
chiefly the domain of physical therapists. See pages 214-215 and 228-229.
pp52-53: Posture work load is described as a primary risk for CTD. Static muscle
contraction reduces circulatory irrigation to muscle, decreasing oxygen and
creating metabolic wastes accumulation in the tissues, leading to pain and
hardening. Muscle posture work should not tolerate more than 5-6% of MVC in work
conditions exceeding one hour. Rapid repetitive motion and high accuracy demands
create increased background tensions in working muscles and tendons, as do noise
and cold, creating similar stresses as seen in excessive posture load demands
and high MVC. Similar stresses are seen when repetitive loading exceeds 50% of
MVC and peak loading exceeds 75% of MVC. Similar stresses are seen in extreme
positions and sudden jerky motions.
pp108-115: Posture load is described as a severe risk particularly in the
presence of short rest breaks. Static posture loads with short rests is a strong
risk. Posture load is a risk especially when posture is awkward or needed to
manipulate tools distally. Speed of repetition increases static posture loads
(Waersted 1986). Forward head posture is seen as a pain source in many static
posture jobs according to one study, suggesting pain is a result of mechanical
deformation of passive tissues (Harms-Ringdahl 1986).
…Static loading is identified as stress causing fatigue and reduction in blood
flow at a time when wastes are increasing and oxygen demands are increasing
(IBID). VDT work is discussed in this context, with up to 95% demonstrating
symptoms (Bjorksten 1984). Management of this risk calls for improving posture
habits, early symptom reporting, redeployment of work, and task alternation.
…Fatigue is the precursor to musculoskeletal pain problems. Repetitive light
tasks produced significant changes in EMG and serum creatine kinase (SCK) in
local muscles. These changes were not seen in heavy aerobic tasks (Hagberg and
Jonsson 1982, 1984). The quality and frequency of rest affects the ability of
muscles to recover (Rhomert).
pp134-143: Forward head posture produces stress through muscles posture load and
passive tissue loads at ROM extremes, where EMG may be quiet. Posture loads at
neck and shoulder are affected by motions, postures and loads in the arms and
hands. Precision, speed, psychological stresses all increased muscle posture loads.
…Neutral upright head posture uses approximately 2% of MVC; slightly flexed
uses 10%; much flexed posture uses 17% of MVC. Trapezius fatigue is reached
where MVC is at 2-5% for more than an hour. This load is greatly increased with
arm flexion or abduction. Flexion was defined as lower cervical flexion with
some compensatory extension at upper cervical, a protracted head posture over
the shoulders (Harms-Ringdahl and Schuldt 1988).
…Work with arms unsupported greatly accelerates fatigue. The more they are
elevated, the more fatigue changes are seen spreading from the upper traps to
the lower traps, thoracic erector spinae, rhomboids and glenohumeral muscles.
Symptoms are related to time spent in forward postures, shoulder elevation, and
total duration of arm activity. Endurance also depended upon the worker’s
physical condition.
…Continuous arm activity entails no return to zero activity, so there is no
relaxation of neck and shoulder muscles. Rather, movement is superimposed on
static contractions. This is in light of the obstruction in perfusion of these
working tissues (Schuldt, Jonsson, Christensen). The use of micro-pause loading
breaks for only a few seconds are important to preserve comfort and work
performance through the work day. When the hands and arms are supported during
work activity, there is less pain in the neck and shoulder region(Hunting,
1981). Elbow support, properly designed, reduced activity in the traps,
rhomboids, and erector spinae in both erect and flexed head positions among
assembly workers (Schuldt, 1987).
pp310+ : Abstracts the papers used in the text. Extensive, highly pertinent
information.
^^Hertling and Kessler: MGT OF COMMON MUSCULOSKELETAL DISORDERS, pp138-140,
Lippincott, 1990.
Pages 138-140: These three pages from this landmark textbook offer a remarkably
clear and detailed description of the pathogenesis of tendinitis and CTD at the
cellular and molecular level. Authors discuss the metabolic and nutrient pathways
for tendons under work stress. It describes tendon breakdown in response
stresses as a nutrient pathway problem, resulting in acute inflammation,
fibrosis and eventual chronic inflammation. It describes the physical properties
of tendon versus scar tissue and its ability to tolerate physical stresses.
Vascularity and nutrient pathway is described as part of pathomechanics. Balance
between rest and activity are discussed relative to work recovery. EXCELLENT!
^^Kelley, M., and Clark, William: ORTHOPEDIC THERAPY OF THE SHOULDER;
Lippincott, 1995; Chapter 3, pp144-149.
These pages provide the very best available description of the various entities
that comprise “thoracic outlet-inlet syndrome.” This is a highly controversial
topic within the medical community, due to varying definitions of what really is
thoracic outlet-inlet syndrome. These pages describe the varied entities that
fall into this category, clarifying the various categories of disorders that may
fall into this diagnosis. This is essential for the prevention specialist to
understand in their work on workplace injury prevention and the role of the
thoracic outlet-inlet.
^^Ellis, J.: “Balancing the Upper Quarter Through Awareness of RTTPB” CLINICAL
MGT, Vol. 7, No. 6
Describes sources of posture dysfunctions for upper quarter problems. These
include TMJ dysfunction, thoracic outlet syndrome, cervical strain, shoulder
problems and headache. Implies a postural relationship among TMJ, neck pain and
upper extremity problems. Describes restoration of erect upper body posture,
correction of breathing mechanics and unloading TMJ stresses posturally as an
essential treatment objective in upper quarter problems.
^^Jackson, P.: “Thoracic Outlet Syndrome: Evaluation and Treatment” CLINICAL
MGT, Vol. 7, No. 6.
This paper describes TOS pathomechanics in details. Prior neck trauma and
abnormal posture habits are identified as risk factors. Correction of posture
habits and body mechanics are identified as foremost in treatment objectives.
Correction of round shoulders slumped postures, scaleni stretching and relaxed
diaphragmatic breathing are recommended.
Joyce, M.: “Ergonomics Will Take Center Stage in the 90’s and Next Century” JOR
OCC HLTH AND SAFETY, Jan 1991.
The American Academy of Orthopedic Surgeons estimates repetitive motion injuries
costs the US $27 billion annually for medical and lost salary costs. One risk is
the young people entering the work force are less physically fit. This is
combined with the increasing age of the worker population, bringing degenerative
and disease risks with age.
**Hansford, P.; et al: “Blood Flow Changes at the Wrist in Manual Workers After
Preventive Interventions”: J HAND SURG: 1968: 11A: 503-508
Manual workers performing repetitive motion tasks were provided a five minute
exercise program. Another group of workers were provided a five minute rest
period. These interventions were performed after 1.5 hours of repetitive motion
work tasks. Radial and ulnar artery blood flow were assessed with the Doppler
method, as was Systolic blood pressure on the dominant extremity. Radial and
ulnar blood flow velocity decreased while Systolic blood pressure remained
stable after the 1.5 hours of manual work. Both the rest and exercise groups
demonstrated increased blood flow velocity, unchanged radial blood pressure and
decreased ulnar blood pressure. The five minute exercise group demonstrated
greater increases in radial blood flow velocity than did the five minute rest
group. Sustained, repetitive motion manual work can produce a decrease in blood
flow through the wrists. Brief exercise programs have been shown to improve
circulation at the wrist after circulation was compromised by the performance of
manual work. Such programs may offer one practical method of preventing soft
tissue injuries related to sustained compromise of blood flow at the wrist.
**Allers, V.: “Workplace Preventive Programs Cut Costs of Illness and Injuries”;
J OCCUP HEALTH & SAFETY: October 1989: 26-29.
Pre-work flexibility stretching exercises have demonstrated significant
reductions in employee musculoskeletal injury and company health care costs.
Warm-up stretching exercises were designed for employees in various work
settings. These exercises emphasized flexibility throughout the spine, lower
extremities and upper extremities. The objective of the exercises was to restore
flexibility through passive stretching, improve blood flow to on-demand tissues
and enhance fitnessand self-care attitudes among employees.
Renco Forest Products in Central Point, Oregon, demonstrated a 91% reduction in
injuries after one year of pre-work stretching exercises on the job. Roseburg
Forest Products of Roseburg, Oregon, reduced lost-time injuries by 80% in one
year with this program. Smurfit Newsprint Corporation in Oregon City, Oregon,
reduced lost-time injuries by 95% in three years since starting the program.
Tigrad Care Center in Portland, Oregon, has reduced lost-time injuries by 78%
and lost work days by 96%. J.M. Smucker’s Company of Woodburn, Oregon, reduced
accidents during its six-month seasonal employment period by 56% and at cost
savings of 95%.
HEBERT,L :”OSHA Ergonomic Guidelines and the PT Consultant,” PT MAGAZINE, Jul.95
This paper describes how stronger OSHA enforcement efforts against Worker
Compensation claims for CTD and back injury represents a tremendous opportunity
to physical and occupational therapists to offer their services to industry as
injury prevention consultants. The OSHA Ergonomic Guidelines 3123 is described
as a format for the consulting therapist to design and present a comprehensive
prevention and ergonomics plan to client workplaces. The paper discusses in
detail the complicating attitude and sociopolitical issues surrounding the
controversy that often accompanies a CTD claims problem in the workplace. This
is described as a primary avenue to follow in evaluating and designing a
comprehensive prevention program. A specific ergonomic risk analysis checklist
and recommendations report is presented as an example of the approach therapists
may take.
^^**HEBERT, L: “Cumulative Trauma Prevention” CLINICAL MGT, Vol 10, No 5,
Sept-Oct 1990
Discusses in detail the format, content and rationale behind the IMPACC CTD
School. Discusses the procedure of marketing and providing this service to
industry. Describes protocol of Work Risk Analysis, management training,
employee worksmart training, preventive exercises, task rotations.
^^**HEBERT, L: “A Change of Place” CLIN MGT, VOL. 8, NO. 6
Discusses the role physical therapist may play as consultants to industry to
help them learn how to understand and resolve their injury risk issues
pertaining to low back and CTD claims. Describes the Back School and CTD School
formats of prevention training in the workplace.
^^**HEBERT, L: “Stretching Exercises in the Workplace” ORTHOP PT PRACTICE,
Vol.11, no.4, 1999
Describes IMPACC stretching program for the workplace; strategies, specifics,
outcomes.
^^**HEBERT, L: “Becoming a Consultant to Industry” ORTHOP PT PRACTICE, vol.12, no.2,
summer 2000
Profiles the services PTs may offer to industry as a consultant: prevention and
treatment services. ergonomics, CTD School, Back School, on-site services,
preferred PT provider arrangements, early intervention-primary care PT
strategies.
^^**HEBERT, L: “Analytic Focus to Preventing CTD” J OCCUP HLTH & SAFETY, Apr
1993.
Describes a comprehensive approach to identifying and correcting hazards for
CTD. Describes a methods of Risks Analysis, Management Education, Employee
Motivation Training and other tactics. Injuries, claims and costs are described
as separate issues, each with its own prevention strategy. Describes the IMPACC
CTD SCHOOL approach to implementing an effective program, particularly to
overcome attitudes and workplace politics that make claims expensive.
^^**HEBERT, L: “Body At Work; Preventive Stretching on the Job” J OCC HLTH
SAFETY, pp48-58, Oct 1992.
This paper describes mechanisms of CTD, strategies for prevention, limitations
of a strictly engineering approach to CTD prevention, and discusses design and
rationale of a preventive stretching program for the workplace. Employers report
significant successes with the plan developed by IMPACC physical therapists.
Table illustrates several successful preventive exercise outcomes with
reductions in CTD lost time days ranging from 60 to 98 percent in the year
following, some with measured increases in productivity. Major feature of the
described exercises is the consideration of proximal structures to be stretched,
i.e. scaleni and other thoracic outlet-inlet tissues
One key feature of these exercises is stretching of the scaleni to open the
thoracic outlet-inlet. Exercises and CTD prevention training program described
in this paper have a ten-year experience history at nearly 300 companies
throughout the US.
^^**HEBERT, L. “A Cumulative Trauma School for Industry” INDUSTRIAL REHAB QUARTERLY,
fall 1992
This article describes the format and strategy of the IMPACC CTD SCHOOL.
Rationales, pathophysiology, and prevention strategies are explained. This
article offers a table summarizing the successful outcomes of eleven companies
that implemented the IMPACC CTD SCHOOL program.
*HEBERT, L “Preventive Stretching Exercises” IND SAFETY & HYGIENE NEWS April
1992.
Preventive stretching exercises for the workplace are described. Outcomes and
rationale are presented, describing successful programs.
^^**HEBERT, L: “The Politics of Work Injury Prevention” IND SAFETY AND HYGIENE
NEWS,May 1992.
Discusses preventing CTD to be more of a political issue than a safety issue,
requiring management training and attitude adjustment prerequisite to ergonomic
efforts and employee behavior changes. Proposes that while it is the
responsibility of management to provide a safe workplace, it is the
responsibility of workers to properly use and care for the working body.
Describes socio-political issues IMPACC addresses in its training program, The
CTD School
^^**HEBERT, L: “New Opportunities for Physical Therapists in Industry” PHYS THER
TODAY, Spring 1991
Describes the opportunities available to physical therapists to present
themselves to industry as consultants on work injury prevention. Describes Work
Risk Analysis services, Back School, CTD School programs for managers,
supervisors and workers. Discusses marketing strategies.
***Lutz, G.; et al: “Cumulative Trauma Disorder Controls: The Ergonomics Program
at Ethicon, Inc.”: J HAND SURG: 1987: 12A (2,part 2): 863-866.
A ten-year experience history of an ergonomics task force for Ethicon, Inc. is
described. The program is based on multiple strategies, including ergonomics,
policy management, training and preventive exercise programs. Medical management
procedures were developed for effective treatment and rehabilitation. Ergonomic
design criteria for new and existing equipment were established. Employee
orientation and education programs were provided to build acceptance of
ergonomics and exercise strategies.
A preventive exercise program was established and studied. Exercises were
performed twice per day per shift for approximately seven minutes each session.
Participation level was voluntary, averaging between 80% - 90%. Prior to the
exercise program, the medical department reported an average of 76 work-related
visits for CTD problems per month. Following the exercise program, three months
later, the medical department reported an average of 28 work-related visits per
month for CTD problems. This is nearly 63% reduction in medical department
visits for CTD-related complaints following initiation of a preventive exercise
program.
**Sawyer, K.: “An On-Site Exercise Program to Prevent Carpal Tunnel Syndrome”:
PROFESSIONAL SAFETY: May 1987: 17-20.
Workers at a racquetball racquet manufacturing facility were experiencing a high
frequency of carpal tunnel syndrome-related problems. From September 1983 until
May 1984, 11 workers were referred for medical attention, two requiring carpal
tunnel relief surgery. A preventive exercise program was initiated in July 1984.
These exercises included stretching of various muscle groups in the neck,
shoulders, arms and hands. Contract-relax exercises were provided for the
fingers and thumb.
From July 1984 through May 1987, there had been only one case of carpal tunnel
syndrome reporting for medical attention. This was successfully corrected with
conservative treatment. It was noted that in May 1986, ergonomic modifications
were made to some tools in a attempt to reduce forearm muscle work demand.
Nearly two years of the exercise program had passed to that point.
***Silverstein, B.; et al: “Can In-Plant Exercise Control Musculoskeletal
Symptoms?”: J OF OCCUP MED”: Vol. 30, No. 12, Dec. 1988: 922-927.
After one year of an on-the-job exercise program to control musculoskeletal
subjective symptoms in the neck and upper extremity, there were no statistically
significant differences in localized posture discomfort. 67% of respondents who
participated in the exercise program reported that the program made them feel
better.
The exercises employed in this study included shoulder joint stretching and hand
squeeze-relax to a bean bag. The author stated that any gain that might have
been made with the exercise program may have been over shadowed by increasing
productivity demands. The authors also pointed out on-going ergonomic problems
with the jobs being studied.
{{ LAUREN’S RESPONSE: Exercise design was questionable. This did not demonstrate
that exercises are useless; this demonstrates that improper exercises are
useless! Ergonomic stresses persisted uncorrected. Production demand increased.
Confusing and contradictory conclusion statement stated there was no difference
in discomfort, yet 67% felt better? }}
***De Vera Barredo R, Mahon K: The effects of exercise and rest breaks on
musculoskeletal discomfort during computer tasks: an evidence based perspective.
J Phys Ther Sci, 2007, vol 19, no 2: 151-163.
A review of research evidence on effects of exercise and rest breaks on
musculoskeletal discomfort during computer work found that evidence supports use
of rest breaks and exercise breaks to reduce discomfort. The evidence, in
aggregate, suggests no additional benefits of exercises over rest breaks. This
review identified widespread problems with research design, internal validity,
statistical analyses, dropout rates and poor subject compliance. This serves to
illustrate the potential value of rest breaks and exercise breaks but identifies
problems with the research in allowing us to reach valid conclusions. This
article is also an excellent demonstration of how to assess the value of
research according to levels of evidence and internal validity.
***Fenety A, Walker JM: Sort-term effects of workstation exercises on
musculoskeletal discomfort and postural changes in seated video display unit
workers. Phys Ther, 2002, 82: 578-589.
Authors examined short term effects of an exercise program on eleven subjects,
involving an exercise break every 30 minutes. Exercises done by video display
unit operators resulted in short-term decrease in both musculoskeletal
discomfort and postural immobility. This is a non-randomized trial where
participants acted as their own controls, resulting in evidence level IV with
moderate internal validity.
***Saltzman A: Computer user perception of the effectiveness of exercise
mini-breaks. In: Proceedings of the Silicon Valley Ergonomics Conference and
Exposition. Silicon Valley, CA, 1998, 147-151.
Authors examined effects of an ergonomics exercise software program of frequent
short stretch breaks. Participants reported stretch breaks were effective in
reducing workplace discomfort. 23 percent of participants reported increased
productivity. 34 percent of participants dropped out of the study. This study
is level V evidence with weak internal validity.
***Thompson D: Effects of exercise breaks on musculoskeletal strain among data
entry operators: a case study. In: Promoting Health and Productivity in the
Computerized Office: Models of Successful Ergonomics Intervention. Taylor and
Francis, 1990, 118-127.
Employees were asked to perform five-minute exercise sessions during their two
regular break periods. Operators reported reduced discomfort and generally
improved physical condition. There were no Worker Compensation claims for one
year into the program. Productivity had increased by 25 percent during the
first four months of the program. Level of evidence is V, with weak internal
validity.
***Karas B, Conrad K: Back injury prevention in the workplace: an integrative
review. AAOHN J, 1996; 44(4): 189-96.
Review of 15 experimental and quasi-experimental studies showed some positive
evidence for back belts, back schools, stretching programs, and educational
classes. Back schools and stretching programs were studied more frequently and
showed the greater proportion of positive results.
***Moore T: A workplace stretching program. Physiologic and perception
measurements before and after participation. AAOHN J, 1998, 46(12): 563-8.
Participants who completed a structured stretching program had zero occurrences
of MSD during the two-month period. There was statistically significant
improvements in flexibility and the Fox Self Perception Profile, suggesting that
flexibility exercises may reduce workplace MSD.
***Hess J, Hecker S: Workplace stretching programs: the rest of the story. Appl
Occup Envir Hyg, 2003; 18(5): 331-8.
Several studies are examined and analyzed in detail, describing positive and
negative findings among a variety of studies and exercise approaches. One study
review included flexibility program for firefighters. Showing no significant
reduction in incidence of LBI, but injury costs significantly reduced ($85,372
for stretch group versus $235,131 for control group) from Hilyer 1990.
***Hilyer J, et al: A flexibility intervention to reduce the incidence and
severity of joint injuries among municipal firefighters. J Occup Med 1990,
32(7): 631-637.
A flexibility program for firefighters showed no significant reduction in
incidence of musculoskeletal injury, but total injury costs significantly
reduced ($85,372 for stretch group versus $235,131 for control group)
Rosta, P.: “Industrial Workers Excel With Work Hardening” REHAB MGT, April-May
1991.
Half of all workers injured on the job never return to work after six months of
absence. 90% recover after 12 weeks. The remaining 10% account for 80% of costs.
Companies rely on ergonomic redesign of work stations. This inadequate since
there is no direct link between ergonomic design and high Worker Comp claims. A
company’s Worker Comp problem is a complex set of economic, political, medical
and legal issues. These must all be considered. Limiting attention to job design
issues is putting a simple band-aid on a very large wound.
**Melnik, M.: “Enlisting Participation in an Injury Prevention and Management
Program” WORK, Fall, 1990.
…Various prevention approaches have been promoted in industry: ergonomic
re-design, employee training, incentive programs, fitness and exercise plans,
supervisor training, and psychosocial strategies. Most claim at least modest
success. There appear to be several common themes that account for success:
genuine management commitment, ongoing efforts to keeps programs alive, employee
willingness to participate. Prevention programs are doomed to failure without
the participation of all parties.
…Therapist consultants to industry must consider existing industry conditions
that may affect outcomes: an existing medical management program, an effective
return to work policy, official employee education system, equipment problem
reporting system, official lines of communication, a physician who understands
the job demands, relations between managers and supervisors, relations between
supervisors and employees, and employee job satisfaction.
…Injury causes fall into two categories: conditions versus behaviors. Programs
that focus just on job design will be helpful when such conditions are at risk,
but industry must be aware that this addresses only one aspect of the problem.
Buying ergonomic chairs does not reduce stress for an employee who does not use
it correctly. Safe work is often a choice. Safe choices require education.
Industry would be naive to believe they can eliminate all risk factors through
design changes.
…The first step is to define unsafe conditions and unsafe behaviors. Unsafe
behaviors are the result of: communication deficits, negative attitudes, poor
physical condition, insufficient knowledge, stress, and lack of proper
supervision. A truly effective program must address behaviors, attitudes,
knowledge and physical condition along with the physical work environment.
…Essential components include: orientation of top managers, work site
evaluation, a task force, employee education, supervisor education, address
strength and flexibility, review sessions, an on-site stretching program, task
force updates, and an incentive program.
Nag P, et al: Influence of arm and wrist support on forearm and back muscle
activity in computer keyboard operation. Appl Ergo. 2009; 40(2): 286-291,
Study examined muscle activity while using a wrist rest, forearm support and
floating (unsupported) upper extremity work posture during keyboard work.
Wrist rest showed mixed reductions in muscle activity, while forearm support
showed widespread reduction in muscle activity compared to forearms unsupported.
Conlon C, Krause N, Rempel D: A randomized controlled trial evaluating an
alternative mouse and forearm support on upper body discomfort and
musculoskeletal disorders among engineers. Occup Environ Med. 2008 May; 65(5):
311-8.
In engineers using computers more than 20 hours per week, a forearm support
board may reduce right upper extremity computer use.
Remple D, et al: A randomized controlled trial evaluating the effects of two
workstation interventions on upper body pain and incident musculoskeletal
disorders among computer operators. Occup Environ Med. 2006 May; 63(5): 300-6.
Comparing ergonomics training only with training plus computer trackball with
training plus forearm support revealed that training plus forearm support was
effective in preventing upper body MSD among call center employees.
Sheley, Elizabeth: “Preventing Repetitive Motion Injuries,” HRM MAGAZINE, Oct.
95.
This article comes from the non-refereed professional journal of human resource
managers in industry. It discusses the introduction of the IMPACC program of CTD
prevention to several workplaces. It describes a three-step approach: work risk
analysis to identify CTD risks, management training to build company and
supervisor commitment and knowledge for identifying and correction risks, and
employee self-protection training. The IMPACC program is specifically
highlighted as being particularly effective in reversing CTD claims. Several
companies using the IMPACC program revealed dramatic reductions in injury
claims. Mike Strakal, PT, of Elkhart, Indiana and Lauren Hebert, PT, of
Portland, Maine, were profiled as IMPACC providers, describing their techniques
and success with the IMPACC program.
P.T. BULLETIN, June 29, 1994: “CTS, Tendon Ailments on the Increase”
UNUM Corp. findings demonstrate CTS increased 308% and tendon disorders 289%
from 1989 to 1993. For men CTS increased 386%, tendon disorders 453% and back
problems by 180%. For women CTS increased 379%, tendon disorders by 239% in the
five year period. Claims for all disabilities increased 78% during that period.
Spinner, R.; et al: “The Many Faces of Carpal Tunnel Syndrome”: MAYO CLINIC
PROCEEDINGS: 64: 829-836, 1989.
This medical paper describes typical and atypical symptom presentations for
carpal tunnel syndrome. The paper discusses differential diagnosis,
electro-diagnostic studies and treatment strategies. The paper describes
secondary or contributory diagnoses, such as “double crush” lesions and pronator
syndrome. It discusses various neuropathies, autonomic reflex contributors and
other disease processes.
^^Jenkins, B: “Differential Diagnosis and Management of Neck Pain”:
PHYSIOTHERAPY: August 1982: Vol. 68, No. 8: 253-255.
This paper describes various neurophysiological and biomechanical processes of
neck and upper extremity pain and dysfunction. It discusses various treatment
strategies. It provides a detailed description of pathology of various neck
conditions.
Of particular note on CTD, this paper describes a central summation phenomenon
whereby nociception originating from various neck tissues due to inflammation or
mechanical irritation can lead to a background of subliminal sensory stimuli
which can increase the central excitatory state. This can lower the threshold of
pain for other peripheral lesions throughout the upper extremity and explain the
apparent correlation between painful shoulder problems, tennis elbow and carpal
tunnel problems in cervical problems. The contribution of the cervical spine
must be considered carefully when presented with one or more of these symptom
complexes.
This paper, therefore, presents one neurological explanation as to how various
and multiple CTD problems throughout the upper quarter may be related to neck
problems. This offers an explanation of the apparent strong relationship between
neck pain problems and carpal tunnel syndrome and tendinitis distally in the
arm.
^^Zacharkow, Dennis, “Sitting Posture: The Overlooked Factor in C.T.S.” ADVANCE
FOR P.T., May 16, 1994
This paper describes in great detail and extensive literature references the
role of sitting posture stress in the etiology of Carpal Tunnel Syndrome,
primarily via thoracic outlet compression caused by forward head posture during
sitting work tasks. Numerous studies are quoted citing the strong relationship
between CTS and TOC and forward head posture. 64% of thoracic outlet patients
had clinical evidence of CTS in one study (Novak, 1993); another showed
virtually 100%. Another study (Glick, 1994) of 500 CTS patients showed 93% had
minor to moderate underlying cervical radiculopathies.
Barrer, S.: “Gaining the Upper Hand on Carpal Tunnel Syndrome” JOURNAL OCC HLTH
AND SAFETY, Jan 1991.
CTD accounts for 48% of claims, up from only 18% less than a decade ago. This is
a function of the shift to automation, requiring more repetitive motion in
sustained postures. Repetition without adequate recovery leads to inflammation.
NIOSH found that 8-9 repetitions per minute did not allow enough recovery time
between repetitions to produce adequate lubrication of moving tissues.
The average high risk workplace will spend $250,000 on these claims per 100
employees per year (1988 dollars). The hidden costs are likely much greater:
damage to morale, for one. Worker who feel the company is not responding
adequately to the problem feel trapped and demoralized, possibly adding t the
problem.
The first step is not to deal with at-risk workers. Rather, one must first
educate management. It is imperative that top management become committed
experts on the issues. The attitude of management will dictate the effectiveness
of any prevention efforts. Only then should one proceed with employee training.
Employee training is essential to ensure their working future. They must conform
to company risk reduction policies, including on-the-job exercises.
Seater, S.: “Physical Therapy Emerging As a Partner in the Corporate Fight To
Contain Costs” P.T. FORUM, Vol. 5, No. 13
Several examples of successful injury prevention and cost reductions following
physical therapy consulting for injury prevention are cited. Westmoreland Coal
reduced back injury lost days by 330, saving $53,130 in employee pay and
benefits alone. Black and Decker reduced medical department visits by 50% with
work station modifications and posture education from a P.T. Adoph Coors Beer
used a P.T. to create a wellness and prevention program that saved them $663,677
in health costs alone. Lockheed Missile reduced back injuries dramatically with
a back injury prevention training program. Public Service of New Hampshire
reduced back injuries by 60% following a similar training process, as did Texas
Instruments. Physical therapists are described as leading authorities on injury
prevention due to their mix of training on musculoskeletal function, making them
ideally suited to prevention programs emphasizing ergonomics.
Will, Robert: “How to Control Worker Comp Costs” NATION’S BUSINESS, March, 1990.
Statistics indicate that people, not workplace conditions, cause 80% of all
injuries. Work habits, attitudes, stress, physical ailments all contribute. Keep
people happy. Injuries and job satisfaction are related. Those with bad
attitudes are far more likely to be injured. Modified duty is vital to reducing
costs. The sooner the return to work, then lower the cost.
Armstrong, T.: “Ergonomics and Cumulative Trauma Disorders”: HAND CLINICS: Vol.
2, No. 3: Aug. 1986: 553-565.
This paper discusses the chronic effects of repetitive work on tendons and
nerves of the upper extremity as it relates to CTD. The author identifies the
list of frequently reported causes or contributors. He discusses various
preventive strategies for re-design of work equipment and procedures. This paper
is a rather exhaustive summary of ergonomic principles and strategies. Various
repetitive motion and posture stresses are described in detail. Tool
modifications are described. An extensive bibliography is also provided.
Schuck, L.: “Handling Carpal Tunnel Syndrome”: ASSEMBLY ENGINEERING: Nov. 1988:
30-33.
This non-medical paper describes carpal tunnel syndrome, its risk factors and
contributory stresses, and various strategies for treatment and prevention. The
paper discusses the role of vibration and other ergonomic contributors. It
discusses the use of a vibrometer as a diagnostic or screening tool. The paper
also discusses splints, vitamin B6, and other treatment strategies. The paper
describes various basic ergonomic modifications in the workplace.
Cannon, L.; et al: “Personal & Occupational Factors Associated With Carpal
Tunnel Synd”: J OCC MED: Vol. 23, No. 4: April 1981: 255-258.
This paper describes case studies of personal and environmental factors
associated with the onset of carpal tunnel syndrome in manufacturing workers.
Particular attention is paid to vibratory hand tools in a history of
gynecological conditions. There are statistical studies regarding years on job,
job type, vibration, diabetes, gynecological conditions, and sex discussed in
the paper
Silverstein, B.; et al: “Carpal Tunnel Syndrome: Causes & a Preventive
Strategy”: SEM IN OCC MED: Vol. 1, No. 3: Sept. 1986: 213-219.
This paper provides an extensive description of occupational risk factors,
non-occupational risk factors and CTS prevention strategies. It identifies
reducing exposure to risk factors such as vibration, worker conditioning and
training to improve work tolerance and modification of work postures. The paper
states a lack of scientifically valid or socially acceptable screening
procedures to identify those at high risk. The paper discusses the value of a
“phasing-in” for training workers new to the job. The paper provides and
excellent basic understanding of injury mechanisms.
Mallory, M.; Bradford, H.: “An Invisible Workplace Hazard Gets Harder to
Ignore”: BUSINESS WEEK: January 30, 1989: 92-95.
This business article describes the extent of the epidemic. It gives a detailed
statistical report as to frequency, costs and growth. It provides a layman’s
description of the problem and its sources. It also discusses simplified
personal ergonomics.
Bleecker, M.: “Recent Developments in the Diagnosis of Carpal Tunnel Syndrome
and Other Common Nerve Entrapment Disorders”: SEMINARS IN OCCUPATIONAL MEDICINE:
Vol. 1, No. 3, Sept. 1986: 205-212.
This paper provides a detailed summary of carpal tunnel syndrome, ulnar nerve
compression, radial nerve compression, peroneal nerve problems, tibial nerve
compression (tarsal tunnel syndrome). The paper discusses various occupational
and non-occupational risk factors. It describes symptomatology, diagnosis,
treatment and prevention.
Erdreich, J.: “VFWS Threatens Your Most Valuable Tool: Employee Hands”: J OF
OCCUP HEALTH & SAFETY: June 1989: 26-28.
This paper described Vibration White Finger Syndrome, particularly
differentiating it from carpal tunnel syndrome. The paper discusses the
similarities and differences between carpal tunnel syndrome and vibration white
finger syndrome. Discusses diagnosis, treatment and prevention.
**Strakal, Michael: “The Magic in Minutes of Exercise,” J. OCC. HLTH. & SAFETY,
Aug 96.
This article comes from the non-refereed professional journal of corporate
safety managers and safety professionals. It is written by a physical therapist
specializing in workplace injury prevention, specifically targeting back and
neck-arm CTD claims. It describes the rationale and experience of
specifically-designed intermittent exercise breaks in the workplace to reverse
the fatigue and potential damage of CTD. Strakal specifically profiles the
IMPACC program and its approach to exercise. It must be pointed out that the
author emphasizes that simply imposing stretching exercises is not effective.
Certain management attitudes, commitment, policies must be first put in place
through effective training. Employees must be taught the rationale behind
exercises and that other steps must also be taken to manage ergonomic risks.
Several companies were described as having experienced dramatic reductions in
CTD claims and costs as a result of the IMPACC program.
Morris, A.: “Program Compliance Key to Preventing Low Back Injuries” JOURNAL
OCCUP HLTH AND SAFETY, Mar 1984.
80% of population will experience back pain. 8% of total worker population will
be disabled during each year. Repeat incidents are the result of incomplete
rehabilitation or inadequate re-entry to work. Employees must be made aware of
the problem and their roles and involvement in it. Employees must understand the
basic structure, function and degenerative processes of the spine to motivate
their compliance with prevention. Using slide of the employees doing at-risk
behaviors will motivate their compliance also.
The frequent and thoughtless use of stressful movements and postures is the
primary risk. Back injury should be identified as a cumulative process. Training
should teach why and how to change at-risk behaviors. Techniques should include
reaching, lifting, posture correction, rest strategies, and simple steps to
restore flexibility and strength. Actual practice of techniques is needed,
customized to the actual jobs, with peer group critique and comment.
Follow-up and vigorous reinforcement is essential to success. Peer support is
essential. Management and supervisors must provide ongoing feedback. The impact
of management attitudes cannot be underestimated!
Nordin, M., et al: “Prevention and Treatment of Low Back Disorders” THE ADULT
SPINE, Frymoyer, J., ed., 1991.
…This paper offers various information of back injury prevention training.
Various studies show some prevention training programs have been very effective
while others have not. The conflicting results appear to be due to varying
company support, teacher qualifications and employee involvement.
…Movements and postures associated with back injury are frequent lifting (>25x
per day), twisting while lifting, heavy lifting (>11.3 Kg), static postures,
forward bending, twisting, and muscle fatigue. The worse appears to be
simultaneous twisting and forward bending, resulting in a six-fold increase in
risk.
…Training workers in materials handling techniques is ineffective.
Inconsistent results appear due to lack of control over materials handling
demands among many workers. Avoiding twisting and keeping the load close appears
to be the most important materials handling methods. Studies have failed to
assess the acquisition of new motor skills as a result of the training. These
skills can be effectively taught. Workers will retain new skills for three
months. Long term retention is seen with on-site feedback and enforcement. 60%
of back injuries can be prevented with safer lifting techniques.
…The firefighters study showed that the unfit are more likely to sustain back
injury. Isometric strength is a poor predictor, as was flexibility.
Nevertheless, fitness programs have shown overall reductions in absenteeism and
costs. Smoking has a positive risk relationship, particularly with disc
herniation. Dissatisfaction with one’s job is a very high risk for injury claims
and costs. One study showed that job dissatisfaction was the number one predictor
for back pain. Management programs have been effective in decreasing accidents.
…Training should be mandatory to assure those most at risk attend. Groups
should be small, between 3 and 12. Audiovisual aids are important. Actual
demonstrations and practice are important. Lifestyle changes is an objective.
Training must fit real life for the students. Development of skills must be
foremost over simple acquisition of knowledge.
Twomey, L. “A rational Approach to the Treatment of Back Pain by Manual Therapy”
PHYS THER, Vol. 72, No. 12, Dec 1992
This author provides an excellent description of the pathophysiology of lower
back degeneration and injury, describing the loss of nutrient pathway and
physical changes due to sustained loading/strain stresses to articular cartilage
and discs and ligament structures. The author discusses flexion loading,
particularly sustained, as a mechanisms of injury and degeneration due to
nutrient pathway changes, fluid dynamics, collagen and cartilage effects.
End-range loading, creep and crimp effects are discussed. The role of passive
extension and pause stretching to prevent injury and reverse many of these
processes is described. Excellent discussion of prevention rationales.
McKenzie, R.: THE LUMBAR SPINE, MECHANICAL DIAGNOSIS AND THERAPY, Spinal
Publications, 1981.
The McKenzie low back care manual. The standard reference on McKenzie protocol,
lordosis lifting methods and mechanisms of disc injury. Extensive description of
mechanisms of disc failure pp16-21.
Hart, D. et al: “Effect of Lumbar Posture on Lifting” SPINE, Dec. 1986.
This LANDMARK research dissertation compares various methods of lifting
techniques and implications for avoiding back injury on materials handling
tasks. Strictly controlled study shows the best method to be one of maintaining
lumbar lordosis during squat lifting. This method is demonstrated to be favored
over the traditional “pelvic tilt” method.
Lumbar flexion moments were least in this lifting posture. Protective muscle
recruitment of erector spinae and obliques was highest with this lifting
posture, particularly during the critical early stage of the lift. An extensive
and valuable bibliography is provided.
Delitto, R., et al: “EMG Analysis of Two Techniques for Squat Lifting” PHYSICAL
THERAPY, Vol. 67, No. 9. Sept 1987.
This study describes the effects on the spine for two different methods of squat
lifting: pelvic tilt versus maintaining lordosis. The researchers discovered
that for pelvic tilt, flexion moment loads were at maximum at the beginning of
the lift while protective contractions of erector spinae and abdominal obliques
were at minimum. During lordosis lifting, protective activity of the erector
spinae and abdominal obliques was highest at the critical early stage of
lifting. It was concluded that lordosis lifting method offered the best
potential muscle protection, particularly during the critical early phase of the
lift.
One of the best papers re motor activity of ES during flexion and lifting in
various postures. Reveals near shutdown of erector spinae and abdom obliques
(needed to stabilize and protect LB structures during lifting) when lifting done
with LB flexion, but high activity during lifting with lordosis preserved. A
landmark paper validating maintaining lordosis during squat lifts (per McKenzie)
to recruit active muscle protection of passive tissues during loading.
Jackson, C. and Brown, M.: “Analysis of Current Approaches and a Practical Guide
to Exercise Prescription” and “Is There a Role for Exercise in Treatment ”
CLINICAL ORTHOP AND REL RESEARCH, No. 179.
Extensive discussion of the design and rationales of various exercise methods.
Notable discussions are offered on the role of obliques, hamstrings, erector
spinae. Excellent critique of otherwise accepted protocols for exercises.
Challenges various traditional assumptions about spine function and exercise,
offering sound research data foundations for challenging traditional
assumptions. Excellent.
Lepore, B. et al: “The Dollars and Sense of Occupational Back Injury Prevention
Training” CLINICAL MGT, Vol. 4, No. 2
1000 Lockheed Missile and Space Co. employees participated in a back injury
prevention training program that resulted in a 67.5% reduction in total back
injury liability costs, a 71% reduction in lost time cases for back injury, a
76% reduction in costs per case, and a 57% reduction in injury cost reserves.
Gatty C, et al: The effectiveness of back pain and injury prevention programs in
the workplace. Work 2003; 20(3): 257-66.
Review of nine studies showed that positive outcomes were associated with
studies reporting high compliance that used job-specific and individualized/small
group education and training approaches.
Schenk R, Doran R, Stachura J: Learning effects of a back education program.
Spine 1996; Oct 1; 21(19): 2183-2189.
The American Back School was compared to a video education group and a control
group. Learning effect was assessed by examining gains in post-test results.
No differences in post-test comparisons were seen in control and video groups.
Significant differences were seen in the back school group at the .001 level,
indicating that back school is an effective intervention for influencing lifting
posture and conveying information on spinal mechanics and lifting technique.
Additionally, video training may not be an effective prevention intervention.
Heymans M, van Tulder M, et al: Back schools for nonspecific low back pain: a
systematic review within the framework of the Cochran Collaboration Back Review
Group. Spine. 2005; 30(19): 2153-63.
There is moderate evidence suggesting back schools in an occupational setting
reduce pain and improve function and return-to-work status.
Karas B, Conrad K: Back injury prevention in the workplace: an integrative
review. AAOHN J, 1996; 44(4): 189-96.
Review of 15 experimental and quasi-experimental studies showed some positive
evidence for back belts, back schools, stretching programs, and educational
classes. Back schools and stretching programs were studied more frequently and
showed the greater proportion of positive results.
Hickey, D., et al: “Relation Between the Structure of Annulus Fibrosus and
Function and Failure of Intervertebral Disc” SPINE, Vol. 5, No. 2
Annulus fibers have the same mechanical properties as tendon fibers, per
tolerance to stretch and strain. Failure of the annulus is most likely to fail
during forward bending loads and during torsion loads. Compression is more
likely to cause end-plate failure. {This paper is often cited as one basis for
not advocating pelvic tilt lifting methods.}
Versloot, et al: “The Cost-Effectiveness of a Back School Program in Industry”
SPINE; Vol 17, No 1, 1992; pp22-27.
A controlled longitudinal study of cost-effectiveness of a Back School for a
Dutch bus company over a six-year period. Results showed a customized Back
School reduced absenteeism by at least 5 days per year per employee, making Back
School cost-effective.
McKenzie, R: “Spinal Assessment & Therapy Based on Pain Behavior” Lecture
handout for BACK PAIN ’92 symposium, Boston, Ma. Dec 1992.
Describes McKenzie method of back pain evaluation and treatment in a concise and
organized manner. Of note: the Quebec Task Force reviewed over 7000 scientific
studies from 1975 to 1985 to identify acceptable methods of categorizing
mechanical back problems. The QTF concluded that a specific diagnosis in LBP is
not possible in 90% of cases. The paper goes on to describe the McKenzie system
of mechanical diagnosis and corrective exercise design.
Daltroy, et al: “A Controlled Clinical Trial of an Educational Program to
Prevent Low Back Injuries” N ENGL J MED 337: 322-328, 1997.
2500 US Postal Service workers underwent back injury prevention training
programs. A similar number were assigned to a control group. a 5.5 year
follow-up revealed no difference between the two groups relative to incidence,
lost days, injury costs, re-injury rates. This study appears to demonstrate for
this group of workers Back School training is ineffective. Authors considered
the possibility management did not take the employee prevention efforts
seriously and employee job dissatisfaction and a negative perception of
management’s attempts to impose prevention efforts. {{Lauren’s note: IMPACC has
had Back School failures at similar postal service settings, apparently due to
hostile employer-employee relations issues.Employee-management relations MUST be
addressed before Back School can be expected to succeed !!}}
Donelson, M. et al: “A Prospective Study of Centralization of Lumbar and
Referred Pain” SPINE, Vol 22, No 10.
This compared the McKenzie method of identifying disc derangements to findings
produced by discographic pain provocation and annular competency. The study
concluded the McKenzie method was actually better than MRI in differentiating
painful versus non-painful discs.
Fritz, Erhard, Hagen: “Segmental Instability of the Spine”, PHYS THER, Vol 78,
No 8
This is a clear, scientific, practical, clinical description of “spinal segment
instability,” probably the best description available anywhere. Excellent!
APTA: “Guidelines for Evaluating Functional Capacity” 1998.
Official guidelines from the American Physical Therapy Association. Describes
pertinent definitions, therapist knowledge base, FCE admissions criteria,
testing methods, outcomes data generation. This is a summary outline, not
instructions on how to do an FCE.
King, et al: “Critical Review of Functional Capacity Evaluations” PHYS THER,
Vol. 78, No. 8, Aug 1998 pp 852-866.
This is the most complete comparative analysis of the top 10 FCE systems
performed to date. Issues of evaluator qualifications, test protocols, validity,
reliability, safety, standards are discussed at length. Important comparative
analyses are illustrated on easy-to-follow tables. This is an excellent analysis
that allows more informed therapist decisions on selecting an FCE system.
Lechner, et al: “Detecting Sincerity of Effort: A Summary of Methods and
Approaches” PHYS THER, Vol. 78, No. 8, Aug 1998. pp 867-888.
Waddell’s nonorganic signs, grip dynamometer validity testing and other
sincerity-of-effort test methods are critically analyzed by way of medical
literature relative to their validity and reliability. Literature review reveals
therapists may be overstepping the bounds of defensible assessment when
assigning a label of invalid or symptom magnification or malingering based on
these tests . Such labels are just not supported by peer reviewed literature
research reports.
McGill, SM: “Low Back Exercises: Evidence for Improving Exercise Regimens” PHYS
THER, Vol. 78, No. 8, Aug 1998. pp 754-765.
An exceptional laboratory analysis of various exercise methods, lifting
techniques, injury mechanisms, including a rare incident that produced a video
fluoroscopy of an instability injury as it occurred. A wealth of valuable
information on lumbar injury and care is provided in this article.
Well-supported suggestions for exercises.
Byl, et al: “A Primate Model for Studying Focal Dystonia and Repetitive Strain
Injury: Effects on the Primary Somatosensory Cortex,” PHYSICAL THERAPY, Vol 77,
No 3, Mar 1997
This study illustrates changes in the brain as a result of repetitve motion
demands at the hand. Repetitive hand motion degrades hand representation in the
sensorymotor cortex of the brain and interferes with motor control. Restoring
hand representation may be a critical part of treatment for patients with RSI.
Solomonow, M, et al “Increased Exposure to Lumbar Injury due to Cyclic Loading,”
Volvo Award, presentation at Intl Soc for Study of Lumbar Spine, as yet
unpublished, 1999.
Repetitive mechanical loading progressively desensitizes mechanoreceptors in
soft tissues of the spine. This results in exponential decrease in protective
reflex muscle activity, increasing risk of injury. Discs, ligaments and other
viscoelastic structures progressively deform (creep) under such repetitive
loads, as muscles lose their ability to stabilize the spine from fatigue,
mechanoreceptor desensitization and neurological habituation. Rest periods
required hours to recover lost tension in experimental tissues (feline model)…
Moffett, J, at al “Benefits of Exercise for patients with Low Back Pain” BRITISH
MEDICAL JOURNAL, July 31, 1999.
Patients were assigned to either a PT-designed exercise program, versus no
exercises beyond general practioner care. 64% of the exercise group had improved
at least three points on a 24-point disability questionaire, compared with 35%
of the non-exercise group.
Zigenfus GC, Yin J, Giang GM, Fogarty WT. Effectiveness of early physical
therapy in the treatment of acute low back musculoskeletal disorders. J Occup
Environ Med. 2000;42:35-39.
Patients referred to physical therapy at day one or day two of back pain onset
needed fewer treatment visits and had fewer lost work days than those referred
later than day two.
Landsmann, M.: “Music Above All,” ADVANCE FOR DIRECTORS OF REHAB, May, 2000.
An excellent review of specifc CTD problems common to musicians. Clear parallels
to industry. Professional musicians are workers, too, after all.
Gross, m., et al: “Relationship Between Lifting Capacity and Anthropometric
Measures”, JOSPT, vol 30, no 5, May, 2000
Various anthropometric measures were taken among men and women of various ages
and related to maximum lifting capacity, using lordotic spine technique. Higher
lifting capacities were discovered among men (vs. women), older subjects (vs.
younger), larger thigh girth (vs. smaller), narrower pelvis girth (vs. wider
pelvis). See next two abstracts for perspectives).
Chaloupka, E., et al: “Metabolic and Cardiorespiratory Responses to Continuous
Box Lifting and Lowering in Nonimpaired Subjects,” JOSPT, vol 30, no 5, May,
2000
Much higher energy expenditure and related cardiopulmonary responses were seen
during squat lifting versus leg-torso coupled flexion lift method. The squat
method employed was a full squat with torso upright, while the leg-torso lift
shared partial knee flexion with forward inclination of the torso (appears to
combine hip flexion with some lumbar flexion. See next abstract for perspective.
McGill, Stuart, “Invited Commentary” , JOSPT, vol 30, no 5, May, 2000
Exceptionally enlightening commentary on the above two articles, in perspective
with several other related studies, noting how all these fit the realities of
the workplace (prevention) and clinic (rehabilitation). Excellent bibliography.
Summary findings include: Continuous lifting is the more valid function to
examine; Experienced lifting workers will use a variety of lifting postures
throughout the work day; Curvature of lordosis important to control lines of
action along many lumbar stabilizer muscles, more beneficial mechanically than
lumbar flexion positions; Spine ROM and strength have little correlation with
future injury; Use of screening measures legally risky and very limited;
Patients should be classified functionally and by specific injured tissues to
determine lifting technique.
Byng J: Overuse syndromes of the upper limb and the upper limb tension test: a
comparison between patients, asymptomatic keyboard workers and asymptomatic
non-keyboard workers. Man Ther 1997, 2: 157-164
The ULTT was positive in 100 percent of the patient group, supporting the
hypothesis that the pathology of occupational upper limb overuse is neurogenic
in origin. Furthermore, the asymptomatic keyboard users (intended to be a
control subgroup) also had a significantly higher positive ULTT compared to
asymptomatic non-keyboard users (the other control subgroup).
Lundborg G, Dahlin L: Anatomy, function, and pathophysiology of peripheral
nerves and nerve compression. Hand Clin 1996; 12(2):185-93.
The clinical stages of nerve compression lesions can be related to changes in
intraneural microcirculation and nerve fiber structure, alterations in vascular
permeability and subsequent formation of edema. The double crush and reverse
double crush syndromes are related to disturbances in axonal transport induced
by compression, followed by morphological and functional changes in nerve cell
bodies.
Edgelow P: Ch.6; Neurovascular consequences of cumulative trauma disorders
affecting the thoracic outlet: a patient-centered approach. In Donatelli R (ed):
Physical Therapy of the Shoulder; 1997; Churchill-Livingstone.
Comprehensive description of pathomechanics and pathophysiology of thoracic
outlet compression.
Federal Register, 11-14-00, Vol. 65, No. 220, Pages 68261-68870, issued Nov 14,
2000
This is the final OSHA Ergonomics Program Rule (cancelled by Congress in Feb
2001). Book Two details the debate and rationale for how and why the Ergonomics
Rule was constructed. Pages 68442 to 68486 discusses injury pathomechanics,
biomechanics, pathophysiology, epidemiology of these MSD’s. Pages 68487 to 68582
details a debate from various parties challenging studies on occupational risks
versus non-occupational risks, offered by various opinionated parties with their
own parochial interests in these rules. An excellent research review and debate.
Reuters News abstract: Radiography Discouraged for Patients With Low Back Pain,
BMJ 2001;322:400-405:
Feb 15, 01 - Radiography is not advisable for patients with low back pain in the
absence of indications of serious spinal disease, even if pain is present for
more than 6 weeks, according to British researchers. Dr. Mike Pringle, of the
School of Community Health Sciences in Nottingham recruited 394 patients with
low back pain of at least 6 weeks’ duration. The patients were randomized to
receive a radiograph of the lumbar spine or to receive usual care from their
doctor. The findings appear in the British Medical Journal for February 17.
Patients who underwent radiography were more likely to report longer duration
and greater severity of pain, reduced functioning, and poorer health status than
those who had no X-rays taken. The investigators surmise that “radiography
encourages or reinforces the patient’s belief that they are unwell and may lead
to greater reporting of pain and greater limitation of activities.”
Approximately two thirds of patient X-rays showed abnormal results, although no
significant differences in outcome were noted between patients with normal
versus abnormal X-rays. In an interview with Reuters Health, Dr. Pringle pointed
out, “Often X-rays show minor abnormalities such as ‘wear and tear.’ These
cannot be treated, as such, and do not affect care.” However, patients who
received X-rays were more satisfied with their care. Even after 9 months, with
improvement in their condition, most patients in both groups said they would
have chosen radiography if the choice had been available. The authors advise
that patient education regarding radiography is important. Dr. Pringle commented
that patients should be told, “The evidence of this study and others shows that
X-rays do not improve therapy decisions or outcomes.”
Reuters Health News: Railroad Ends DNA Testing in Wake of Lawsuit
NEW YORK Feb 13, 01 - The Burlington Northern and Santa Fe Railway Company said
yesterday that it would stop DNA testing for carpal tunnel syndrome. The US
Equal Opportunity Employment Commission (EEOC) on Friday filed a lawsuit
challenging the railroad’s DNA testing program as a violation of the Americans
with Disabilities Act. The lawsuit, filed in federal court in Sioux City, Iowa,
is the EEOC’s first court action challenging genetic testing. Burlington
Northern, based in Fort Worth, Texas, also agreed to suspend testing that would
identify a genetic cause for carpal tunnel syndrome in response to employees’
work-related medical claims for carpal tunnel. According to the EEOC’s
complaint, employees who submitted carpal tunnel claims were required to provide
blood samples that were screened for Chromosome 17 deletion, said to be
associated with a genetic predisposition for carpal tunnel syndrome. Laurie A.
Vasichek, an EEOC senior trial attorney, told Reuters Health that the agency has
agreed not to pursue a preliminary injunction for 60 days in exchange for
Burlington Northern’s agreement not to conduct further genetic testing or to use
test results. If by that time it is unable to reach a legally enforceable
agreement with railroad officials, the EEOC will pursue a preliminary
injunction, she said.
“Ergonomic Interventions for Low Back Pain: Is the Glass Half-Full or
Half-Empty?” BACK LETTER 16(3):25, 32-34, 2001, Lippincott Williams & Wilkins
When it comes to the efficacy of ergonomic interventions to prevent low back
pain, high-quality scientific studies and lesser-quality studies tell two
different tales. Therein lies a dilemma for public policy makers and health care
providers. Accurate characterization of evidence on ergonomic interventions has
significant economic and public health implications. Congress recently killed
the OSHA’s sweeping ergonomic regulation, largely because of a lack of clear
evidence demonstrating its effectiveness and cost-effectiveness. Implementation
of the regulation was projected to cost industry anywhere from $4 billion to
$125 billion per year. So what is an accurate assessment of the potential of
ergonomic interventions to prevent low back pain? A judgment based solely on
well-designed randomized controlled trials suggests the following: There is no
conclusive evidence that reducing physical exposures in the workplace can
prevent low back pain or low back pain disability. Similarly there is no
conclusive evidence in favor of ergonomic job redesign or reorganization of the
production process. The impact of altering organizational culture hasn’t been
adequately explored in high-quality studies. A recent review of the ergonomic
literature by the National Academy of Sciences (NAS) offers starkly different
conclusions: “Data from scientific studies of primary and secondary
interventions indicate that low back pain can be reduced under certain
conditions by engineering controls (e.g. ergonomic workplace redesign),
administrative controls (specifically, adjusting organizational culture),
programs designed to modify individual factors (specifically employee exercise),
and combinations of these approaches,” according to the NAS report. The NAS
authors based these findings on a quirky three-part review of the evidence on
ergonomic interventions. To make these conclusions the NAS panel had to dip into
studies of dubious scientific quality and make some judgments that others might
interpret as leaps of faith. (See National Research Council and the Institute of
Medicine, 2001.) These conflicting views of the scientific evidence raise the
obvious question: “Which approach is correct?” Should scientific reviews and
public policy be guided by high-quality evidence or by the broader spectrum of
research? The editorial stance of the BackLetter is that conclusive judgments
should be based solely on high-quality evidence and that lesser-quality studies
should serve to generate hypotheses for further high-quality research. This is a
tough standard, but allows an accurate characterization of the scientific
evidence at any given time. And it doesn’t require speculation and guesswork.
Based on that evidence standard, the NAS report appears to have come to
inaccurate conclusions about the scientific data regarding ergonomic
interventions.The NAS panel made the following conclusions after looking at the
six pre-existing reviews of the ergonomic literature:.”Collectively, the data in
these six reviews indicate that certain engineering controls [e.g. ergonomic
workplace redesign], administrative controls (specifically adjusting
organizational culture), modifying individual factors (specifically, employee
exercise), and the inclusion of a combination of interventions are the only
strategies that have been shown to be positively associated with the reduction
of work-related low back pain,” the NAS panel concluded. However, this
conclusion is not an entirely accurate characterization of these reviews — if
one applies the NAS panel’s requirement that only studies with control groups
should be considered. The reviews did not identify any studies with
contemporaneous control groups that found a benefit for engineering controls
(workplace redesign). These reviews did find controlled studies in favor of
adjusting organizational culture and exercise. However, almost all the studies
cited in the six reviews have major methodological flaws, as the reviews
themselves point out. In some respects, the research effort to identify
effective back pain prevention strategies has been a failure. Despite the best
efforts of talented researchers, the back pain and disability crisis continues
to rage. According to the NAS report, the overall prevalence of musculoskeletal
disorders and related disability in the general population of the United States
is still rising Perhaps ergonomic interventions aimed at reducing physical
exposures have the potential to stem the back pain and disability epidemic, as
the NAS panel asserts. However, there is as yet no solid scientific
documentation of this, despite 50 years of research.
Using Computer Doesn’t Increase Risk Of Carpal Tunnel Syndrome, Study Finds
Source: American Academy Of Neurology
Posted 6/12/2001… ST. PAUL, MN Using a computer at work doesn’t increase
your chances of developing carpal tunnel syndrome, according to a study
published in the June 12 issue of Neurology, the scientific journal of the
American Academy of Neurology. “We wanted to do this study because conventional
wisdom says that using a computer increases your risk of developing carpal
tunnel, but few studies have been done to see how often carpal tunnel actually
occurs in computer users,” said study author and neurologist J. Clarke Stevens,
MD, of the Mayo Clinic in Rochester, Minn. Stevens said most of the studies
showing that repetitive motion causes carpal tunnel involve workers in
meatpacking plants or other industrial jobs, not computer users. This study
examined 257 employees at the Mayo Clinic in Scottsdale, Ariz., who used a
computer frequently in their jobs. “Many of the computer users in the study had
experienced feelings of numbness or ‘pins and needles’ in their hands, but the
percentage who actually met the medical criteria for carpal tunnel syndrome was
similar to other estimates of how often carpal tunnel occurs in the general
public,” Stevens said. For the study, researchers sent a questionnaire to
employees who used computers for much of their jobs, such as secretaries and
transcriptionists. They reported using the computer for an average of six hours
per day. Of the 257 people studied, 30 percent said they had experienced pins
and needles sensations or numbness in their hands. Those people then completed a
questionnaire on carpal tunnel symptoms and a diagram to show where their
symptoms occurred to determine whether they met the clinical criteria for carpal
tunnel syndrome. Twenty-seven people met the criteria, or 10.5 percent of the
original study group. Stevens said those who had symptoms of numbness or
tingling but did not have carpal tunnel had mild symptoms that occurred briefly.
Some may have had problems with another nerve in the arm, the ulnar nerve.
Carpal tunnel affects the median nerve. The researchers then tested the nerves
of those who met the criteria to see if electrodiagnostic laboratory tests would
confirm the diagnosis. The nerve conduction studies confirmed the diagnosis in
nine people, or 3.5 percent of the 257 study participants. “These percentages
are similar to percentages found in other studies looking at how often carpal
tunnel occurs in the general population — not just computer users,” Stevens
said. The researchers also found no significant differences between the computer
users who had carpal tunnel and those who did not. “They had similar
occupations, number of years using the computer and number of hours using the
computer during the day,” Stevens said. “So there were no differences that might
point to computer use as a factor in causing carpal tunnel.” Stevens said the
results shouldn’t be interpreted to mean that the repetitive motions involved in
using a computer can never lead to problems for people. “There are a lot of
aches and pains associated with using a computer,” he said. “We just found that,
at least in this group, frequent computer use doesn’t seem to cause carpal
tunnel syndrome.” Additional studies with large groups of people should be done
to see if these results can be confirmed, Stevens said. Note: This story has
been adapted from a news release issued by American Academy Of Neurology for
journalists and other members of the public. If you wish to quote from any part
of this story, please credit American Academy Of Neurology as the original
source. You may also wish to include the following link in any citation:
https://www.sciencedaily.com/releases/2001/06/010612065139.htm
Lechner, D. “PREWORK SCREENS: AN OPPORTUNITY FOR PREVENTING INJURIES”, OTHRO PT
PRACTICE, vol 13, no 2, 2001
Important legal considerations as you develop a pre-work screening process to
offer to employers. Excellent discussion on how to succeed with this venture.
Deb describes one format for providing pre-work screening. Compare that to the
alternative method we at SmartCare provide, as it is a quite different approach,
serving a different objective.
Mitchell JM, de Lissovoy G. Comparison of resource use and cost in direct access
versus physician referral episodes of physical therapy. Phys Ther. 1997;77:10-18
Study conducted by Dr. Jean Mitchell of Johns Hopkins University and Dr. Greg de
Lissovoy of Georgetown University concluded that states and insurance companies
that reimburse under direct access will realize cost savings of approx. $1200
per patient episode of care (www.apta.org). They also cite a study performed in
1994 which found that the costs incurred for physical therapy visits were 123%
higher when patients were first seen by a physician than when they went to a
physical therapist directly. This study also showed that physician referral
episodes generated 67% more physical therapy claims and 60% more office visits
than did episodes when the patient went directly to the physical therapist
without a physician referral
Liability Insurers and the Federation of State Boards of Physical Therapy
(Health Providers Service Organization, in a March 22, 2001, letter to the
APTA-on file)
affirms that direct access does not jeopardize the health, safety, or welfare of
the patients/clients seeking physical therapists’ services without referral.
Health Providers Service Organization, the leading liability insurer of physical
therapists in the united states, indicates in a March 22, 2001, letter that
“direct access is not a risk factor that we specifically screen for in our
program because it has not negatively impacted our claims experience in any way.
In addition, we do not have a premium differential for physical therapists in
direct access states.”
Kolarczyk, D. “SUCCESSFUL ONSITE THERAPY”, OTHRO PT PRACTICE, vol 13, no 2, 2001
A brief but excellent overview description of onsite PT services you may bring
to client workplaces. This paper emphasizes outcomes measures you may use to
track success and savings for client workplaces, a critical component to getting
in the door of industry.
Ritch, J. “MARKETING YOUR PT PRACTICE TO EMPLOYERS, OTHRO PT PRACTICE, vol 13,
no 2, 2001
An excellent lesson on marketing (so deficit a skill among most PT’s!), from
basic principles to specific tactics for industry. Essentially provides us a
marketing plan for our industrial PT specialty.
Charney & Gasterlum: “Lift Teams - A one-year study: Another success story in an
acute-care hospital” J Healthcare Safety, Compliance & Infect Control, 2001,
Vol. 5, No. 2.
A one-year study was undertaken in a San Diego, California, acute-care hospital
to test the viability of using lift teams to reduce workers’ compensation claims
due to lifting patients. The hospital has an approximate daily patient census of
350 with 2,000 employees. A multidisciplinary team was organized over a
six-month period to develop the lift team and create parameters of
implementation. A policy and procedure were developed that mandated nursing to
use the lift team during its shift, and, for off-shifts, nursing had to use
mechanical lifting equipment to generate a “no manual lift” policy. The job
description of the lift team mandated that the team had to use mechanical
lifting equipment for every total body lift of a patient. A mechanical lift
inventory was completed prior to implementation, and the hospital discovered
that it had very few mechanical lifts in the facility. A budget of $160,000 was
allocated to purchase mechanical equipment. The equipment inventory purchased
was as follows: two total-lift lateral transfer stretchers per floor; and one
vertical lift per floor.Injuries during the study period were reduced from 22
lost-time injuries to six. Days lost were reduced from 744 to zero, and workers’
compensation costs were reduced from $224,000 (hard costs, considered only
compensation and medical) in the prior year to $14,000 during the study year.
NYTimes.com…March 12, 2002… Prevention: Benefits of Being Ergonomically
Correct… By ERIC NAGOURNEY
A study found equiping 356 state employees with workstations to reduce
repetitive stress injuries led to a significant percent in computer-related
health complaints in less than a year. Employees in the Office of Information
Technology in New Jersey reported substantially fewer musculoskeletal problems
at their backs, elbows, arms, hands, necks and eyes, according to a study in the
Proceedings of the Human Factors and Ergonomics Society conducted by Dr. Alan
Hedge of Cornell University and Mary Rudakewych and Lisa Valent-Weitz of the New
Jersey Health and Safety Office. The workers received ergonomic chairs, which
provide good back support and can be easily adjusted; negative slope keyboard
trays, which are highly adjustable; and mouse platforms that sit over the
keyboards. Employees were trained in the use of the equipment, and were also
offered accessories like document holders, antiglare screens and footrests. The
workers were surveyed before the equipment was in place and about eight months
later. In the first survey, only 16 percent reported no symptoms. In the second,
more than 40 percent were free of symptoms. But Dr. Hedge said good equipment
alone was not enough and emphasized the importance of taking breaks.
BACK BELTS …Kraus, Jess, et al: “Reduction of Acute Low Back Injuries by Use
of Back Supports,” INTL J OCCUP & ENVIR HLTH, Oct-Dec 1996, Vol. 2 (3).
This paper is a well-controlled study of the effectiveness of low back support
belts in reducing low back injuries. The study was sponsored by UCLA School of
Public Health and the Southern California Injury Prevention Research Center as
an objective study independent of the back support industry. The study of 36,000
employees at 31 Home Depot stores in California encompassing 101,000,000 work
hours revealed a decrease of 34% in low back injuries following a mandatory
policy on use of back supports among employees. Favorable effects were seen in
both genders, young and old, new or experienced workers, low lifting intensity
and high lifting intensity jobs. The study provides scientific evidence that
proper use of back supports as part of a comprehensive back injury prevention
program. can be effective in reducing back injuries.
BACK BELTS .. Kraus, J, et al: “Back Supports & Low Back Injuries: a Second
Visit with the Home Depot Cohort Study Data”, INT J OCCUP ENVIRON HEALTH, 1999,
5:9-13
This paper revisits data for the study demonstrating significant favorable
effects of wear back supports in the workplace, to answer the firestrom of
criticism from ergonomics professionals seeking to discredit the report. All the
questions raised were examined and assessed for validity and objectivity. All
issues were fully answered, reinforcing the validity of the findings that back
supports did indeed reduce back injury lost days by 34% among 36,000 Home Depot
employees over a six year period.
BACK BELTS .. Allen, S.K. and Wilder, K. “Back belts pay off for nurses”, Occ.
Health & Safety, 65 (1) (1996) 59-62.
back belts - the general use of back belts in the distribution industry has been
questioned. However, in a study of 47 employees over a 6-month period, the use
of back belts significantly reduced injury risks. The test group with back belts
worked 22,243 hours and had no injuries, whereas the control group worked 23,109
hours and lost 80 hours due to back injuries
BACK BELTS .. Warren, L, et al, “Effects of Soft Lumbar Support Belt on
Abdominal Oblique Muscle Activity in Nonimpaired Adults During Squat Lifting” J
ORTHOP SPORTS PHYS THER, June, 2001; 31
Wearing a soft lumbar support during squat lifting significantly decreases
activity of abdominal obliques. This study shows back belts reduce muscle
activity and this should be consistent with decreased loads on the spine, likely
due to increased intra-abdominal pressure. This is consistent with other studies
that, taken together, demonstrate the both abdominal and back muscles produce
less force during lifting with a back support. Decreased coactivation of the
muscles around the spine suggests that spinal compressive forces are decreased.
Loads on the spine during lifting tasks are positively correlated with increased
muscle activity. Intra-abdominal pressure is significantly increased with
wearing a back belt during lifting. Increased intra-abdominal pressure is
believed to result in decompression of the spine during loading and decreased
load on spinal muscles. There is also an increased recruitment of quadriceps
muscle action during lifting with back belts, suggesting they encourage improved
lifting technique.This paper mentions numerous studies in its text and its
bibliography that add support to the hypothesis of the authors.
BACK BELTS .. Giorcelli RJ, et al: “TTHE EFFECT OF WEARING A BACK BELT ON SPINE
KINEMATICS DURING ASSYMETRIC LIFTING OF LARGE AND SMALL BOXES” SPINE,
2001;26(16):1794-8.
28 subjects with at least six months’ materials handling experience and no
histories of low back pain were involved in structured lifting tests, wearing
the flexible back support and not wearing it. The research evaluated the effect
on spinal kinematics (flexion, right and left bending, and right and left
twisting, and lifting velocity) on experienced materials handlers wearing
no-suspenders, flexible back supports (“belts”) and lifting both small and
larger boxes. Their results indicated that, under most test conditions, the
“subjects with belts lifted more slowly and used more of a squat-lift technique,
regardless of box size. Belts reduced more torso motions while lifting large
boxes.” Further, they state that, “belt use significantly affected spine
kinematics by decreasing maximum spine flexion, maximum spine flexion angular
velocity, maximum spine extension angular velocity, maximum torso left lateral
bending velocity and maximum torso right lateral bending, and maximum torso left
twisting for lifts with the large box.” These findings indicate that belts offer
the worker the reminder to lift object in a less-risky manner (less flexion and
more deliberate movement), something previous research has been advocating for
years. The authors were not willing to draw the conclusion themselves, but their
results indicate that, under the test conditions, the belts offered workers a
substantial protective effect. The flexible back support they tested was
associated with subject behavior that has been shown to be protective against
low back pain and injury.
^^ D M Rempel, “A randomized controlled trial evaluating the effects pain of two
workstation interventions on upper body pain and incident musculoskeletal
disorders among computer operators” Occup. Environ. Med. 2006;63;300-306
Forearm Support Reduces Pain among Computer Users… A simple workstation
modification, the addition of a forearm support, was found to reduce upper body
pain and prevent musculoskeletal disorders among customer service workers who
use a computer for more than 20 hours per week. In this randomized controlled
trial, the 182 participating workers were followed for 1 year. Based on a
cost-benefit analysis, employers could see a full return on the cost of
providing arm boards to all employees within 11 months of the investment. The
Morency rest forearm supports are manufactured by R&D Ergonomics of Maine. The
study received the 2006 International Ergonomics Association/Liberty Mutual Prize
MacDermid,J., “Clinical & Electrodiagnostic Testing of carpal Tunnel Syndrome”,
JOSPT, OCT 2004
Excellent review of various simple non-invasive diagnostic testing for CTS, with
correlations to Electrodiagnostic testing. Includes highly valid testing per
history, sensory screening, provocation tests, NVC-EMG.
Michlovitz, S., “Conservative Interventions for CTS,” JOSPT, OCT 2004
Excellent review of current PT approaches to clinical management of CTS.
Lee, M, “Pronator Syndrome and Other Nerve Compressions That Mimic CTS,” JOSPT,
OCT 2004
Differential assessment of median nerve compressions of the upper extremity
proximal to the wrist, mimicking CTS, along with treatment approaches for these.
Barr, A, “Work-Related Musculoskeletal Disorders of the Hand and Wrist,” JOSPT,
OCT 2004
Epidemiology, pathophysiology and sensorimotor changes are reviewed. Reviews
many studies. Of particular note is the description of pathophysiology,
especially describing histochemical changes that can trigger inflammatory
responses systemically. Cytokines are released from local inflammatory sites may
trigger systemic inflammatory responses, thus causing tendinitis symptoms to
spreading to other sites. Of equal interest is the motor behavior degradation
that can occur with repetitive motion tasks, causing loss of motor control and a
resulting loss of coordination and movement efficiency that may increase work
damage. This may be the result of changes at the brain where repetitive movement
causes degradation of motor cortex, distorting motor control. This is
reorganization of CNS control of movement.
^^ Novak, C, “Upper Extremity Work-Related Musculoskeletal Disorders: a
Treatment Perspective,” JOSPT, OCT 2004
This is an excellent discussion of various important pathomechaics of MSD. Of
particular interest is the prevalence of multi-level neurovascular compressions
(double-crush) {{a critical issue in prevention tactics where we address
proximal posture risks to reduce distal repetitive motion problems}}. Static
postures, particularly at the neck are also described {{another critical issue
in prevention tactics where we address proximal posture risks to reduce distal
repetitive motion problems}}. Posture risks at various articulations are
described. Treatment approaches are also well-described in this paper.
Barr, A, Barbe, M: Pathophysiological Tissues Changes Associated with Repetitive
Movement: A Review of the Evidence. Phys Ther. 2002 February: 82(2): 173-187.
This article presents several key considerations defining MSD pathophysiological
mechanisms taken from extensive literature review, particularly among animal
studies describing neuromusculoskeletal responses to repetitive or sustained
loading demands. Key points include:
CELLULAR CHANGES:
Muscle tissue biopsies of humans with hand overuse symptoms showed histological
and muscle fiber structure changes consistent with denervation or ischemic loss
of type II fibers with hypertrophy of type I fibers. Upper trapezius samples
showed changes consistent with hypoxia and reduced blood flow. Structural
damage to tissues usually stimulates proliferation of progenator cells of that
tissue. Cell membrane damage releases intracellular factors that stimulate
infiltration of lymphocytes and macrophages. These processes stimulate
regreneration, or scarring if that damage is ongoing. In tendons this can
result in fibroblast proliferation leading to fibrosis and collagen dysplasia
within the extracellular matrix.
Ongoing mechanical or metabolic stress such as hypoxia, ischemia or inflammation
leads to release of heat shock proteins (HSP) by cells such as neurons, glia,
fibroblasts and muscle cells. This is a healing protective response whereby
these HSP restore denatured proteins. HSP are stimulated by ischemia or tears
in cell membranes releasing cytotoxic free radicals. Cell damage releases
cytokines, mediators of inflammation, cell proliferation and regeneration.
Cytokines are proinflammatory proteins including interleukins, tumor necrosis
factor (TNF), COX2 and prostaglandin. These mediate proliferation of
macrophages and fibroblasts. The phagocytic action of the macrophages can
further increase damage and release more cytokines, thus creating a vicious
cycle of chronic inflammation. Damaged cells release chemicals that damage more
cells. This cycle is prolonged and magnified when exposure to repetitive tasks
is ongoing.
CNS CORD CHANGES:
Chronic pain can lead to neuroplastic changes in nerves, cord and cortex.
Sustained nociception afferent bombardment can increase release of excitatory
neurotransmitters glutamate and substance P within the dorsal horn. These can
activate and potentiate synapse activity both presynaptically and
postsynaptically. This can also alter genetic expression in neurons to
upregulate receptor sites. The end result is hyeralgesia (increased sensitivity
to nociception) and allodonia (non-painful stimuli felt as pain). Clinicians
often mistake this process as “symptom magnification” or psychological
complications. Nerve constriction peripherally due to repetitive or sustained
mechanical compression can also cause neuroplastic changes in the dorsal root
ganglion that can increase nociception transmission.
CNS CORTEX CHANGES:
Repetitive tasks can induce changes in cerebral cortex, particularly
de-differentiation of cerebral cortex representation of the hand. This is
induced by constrained and repeated motions at the upper limb. Loss of specific
hand field representation of the cortex causes loss of coordination and changes
in movement behaviors toward less efficient motor control. This loss of
movement efficiency increase fatigue and pain risks during repetitive tasks.
This is maladaptive movement behavior. It may be that this motor control
degradation precedes the onset of pain and may even precipitate it.
SYSTEMIC INFLAMMATORY REACTION
Animal studies of this phenomenon revealed increased cellular chemical changes
described above: increased HSP-72, COX2, and macrophage infiltration at levels
1000 times above baseline. BUT of particular note… these biochemical changes
were seen also in the non-moving control limbs, suggesting a systemic
inflammatory response to the high repetition low load tasks in the experiment.
This suggests that repetitive task work can lead to not only local inflammatory
reactions at the exposure site, but also leads to a wider systemic inflammatory
response as well as neurological reorganization (neuroplasticity) centrally at
the spinal cord, increasing nociception, and at the cerebral cortex, causing
motor control degradation.
Reis, Eric, “Working Solutions: PTs & Ergonomics” PT MAGAZINE, Sept. 2004
An excellent description os the services PTs may provide to industry. Describes
several PT workplace consulting practices. Gives good description of PT’s
qualifications and opportunities for this line of work. Good outcomes are also
provided. Good web abd literature references. Excellent.
** Butler, David: THE SENSITIVE NERVOUS SYSTEM; Noigroup Publ, Adelaide,
Australia, 2000.
The is an exceptional text on the neurophysiology of pain, with critical
reference to neurovascular entrapment, AIGS, double crush, neural mobility,
central excitation, upregulation of pain, and other issues that closely relate
to extremity pain syndromes, particularly those involved with work disorders.
Excellent description of underlying issues important to dealing with injured
workers. Addresses mobilization of the peripheral nervous system, which may be
a part of the stretching tactics we may consider for the workplace.
IMPORTANT WEB SITES OFFERING TOOLS FOR MSD-ERGONOMICS ASSESSMENT AND RISK
CORRECTIONS..
https://www.ergo.human.cornell.edu/cutools.html
NIOSH LIFTING EQUATION…
https://www.cdc.gov/niosh/docs/94-110/
https://www.ergonomics.com.au/niosh.htm
ERGONOMICS ARTICLES CATALOG…
https://www.workriteergo.com/ergonomics/articles.asp
WASHINGTON STATE ERGONOMICS TOOLS…
https://www.lni.wa.gov/Safety/Topics/Ergonomics/ServicesResources/Tools/default.asp
The effect of cervical traction combined with conventional therapy on grip strength on patients with cervical radiculopathy. Joghataei MT, Arab AM, Khaksar H. Clin Rehabil 2004; 18(8): 879-887
Authors Conclusions: Both the experimental and control groups demonstrated an improvement in the hand grip function in patients with cervical radiculopathy. The improvement between groups was not different after 10 sessions, although after 5 sessions the improvement was greater in the traction group as compared to the control group.
Achilles Pain, Stiffness, and Muscle Power Deficits / Achilles Tendinitis: CLINICAL GUIDELINES:CHRISTOPHER R. CARCIA, PT, PhD • ROBROY L. MARTIN, PT, PhD, JEFF HOUCK, PT, PhD • DANE K. WUKICH, MD. J Orthop Sports Phys Ther. 20XX:XX(_):A_-A_.
Back schools for non-specific low-back pain. (Review)
Heymans MW, van Tulder MW, Esmail R, Bombardier C, Koes BW
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2010, Issue 3
https://www.thecochranelibrary.com
Manipulative treatment vs. conventional physiotherapy treatment in whiplash injury: a randomized controlled trial. Fernandez-de-las-Penas C, Fernandez-Carnero J, Palomeque del Cerro L, Miangolarra-Page JC. J Whiplash Relat Dis 2004; 3(2): 73-90
… protocol includes high velocity-low amplitude techniques of the upper cervical spine, cervicothoracic junction, thoracic spine, thoracolumbar junction and pelvic girdle; neuromuscular technique in paraspinal soft tissues; muscle energy techniques in the cervical spine; craniosacral techniques, and myofascial trigger point manual therapies.
… clinical trial have demonstrated that manipulative treatment is more effective in the management of whiplash injury than conventional physiotherapy treatment.
Three-MHz Ultrasound Heats Deeper Into the Tissues Than Originally Theorized.
Hayes BT, Merrick MA, Sandrey MA, Cordova ML.Oregon State University, Corvallis, OR. J Athl Train. 2004 Sep;39(3):230-234.
…results suggest that 3-MHz ultrasound heats 0.5 cm deeper than suggested by others. With our machine, 3-MHz ultrasound was more effective in heating muscle at this depth than 1-MHz ultrasound.
Acute low back pain with radiculopathy: a double-blind, randomized, placebo-controlled study. Konstantinovic LM; Kanjuh ZM; Milovanovic AN; Cutovic MR; Djurovic AG; Savic VG; Dragin AS; Milovanovic ND. Clinic for Rehabilitation, Medical School, Belgrade, Serbia. Photomedicine And Laser Surgery [Photomed Laser Surg] 2010 Aug; Vol. 28 (4), pp. 553-60. Publication Type: Journal Article Language: English
CONCLUSIONS: The results of this study show better improvement in acute LBP treated with LLLT used as additional therapy.
CLINICAL GUIDELINES: Achilles Pain, Stiffness, and Muscle Power Deficits / Achilles Tendinitis:
Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. CHRISTOPHER R. CARCIA, PT, PhD • ROBROY L. MARTIN, PT, PhD. JEFF HOUCK, PT, PhD • DANE K. WUKICH, MD
J Orthop Sports Phys Ther. 20XX:XX(_):A_-A_.
- Interventions – Eccentric Loading: Clinicians should consider implementing an
eccentric loading program to decrease pain and improve function in patients with midportion
Achilles tendinopathy. (Recommendation based on strong evidence).
- Interventions – Low Level Laser Therapy: Clinicians should consider the use of low level
laser therapy to decrease pain and stiffness in patients with Achilles tendinopathy.
(Recommendation based on moderate evidence).
- Interventions – Iontophoresis: Clinicians should consider the use of iontophoresis with
dexamethasone to decrease pain and improve function in patients with Achilles tendinopathy.
(Recommendation based on moderate evidence).
- Interventions – Stretching: Stretching exercises can be used to reduce pain and improve
function in patients with Achilles tendinopathy. (Recommendation based on weak evidence).
- Interventions – Foot Orthoses: A foot orthosis can be used to reduce pain and alter ankle and
foot kinematics while running in patients with Achilles tendinopathy. (Recommendation based
on weak evidence).
- Interventions – Manual Therapy: Soft tissue mobilization can be used to reduce pain, improve
mobility function in patients with Achilles tendinopathy. (Recommendation based on expert
opinion).
- Interventions – Taping: Taping may be used in an attempt to decrease strain on the Achilles
tendon in patients with Achilles tendinopathy. (Recommendation based on expert opinion).
- Interventions – Heel Lift: Conflicting evidence exists for the use of heel lifts in patients with
Achilles tendinopathy. (Recommendation based on conflicting evidence).
- Interventions – Night Splint: Night splints are not beneficial in reducing pain when compared
to other forms of interventions for patients with Achilles tendinopathy. (Recommendation based
on weak evidence).
Back schools for non-specific low-back pain. (Review) Copyright © 2010 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
… There is moderate evidence that back schools conducted in occupational settings seem to be more effective for patients with recurrent and chronic LBP (as opposed to patients from the general population or primary/secondary care) than other treatments, placebo or waiting list controls for pain, functional status and return to work during short and intermediate-term follow-up.
Transcutaneous electrical nerve stimulation for the management of neuropathic pain: the effects of frequency and electrode position on prevention of allodynia in a rat model of complex regional pain syndrome type II. Phys Ther. 2006;86:698 –709. Somers DL, Clemente FR.
… results indicate that TENS delivered contralateral to a nerve injury best reduces allodynia development. Comprehensive reduction of allodynia development would require a combination of high- and low-frequency TENS intervention.
Manipulative treatment vs. conventional physiotherapy treatment in whiplash injury: a randomized controlled trial. J Whiplash Relat Dis 2004; 3(2): 73-90 Fernandez-de-las-Penas C, Fernandez-Carnero J, Palomeque del Cerro L, Miangolarra-Page JC
… manipulative protocol developed by the investigation group was demonstrated to be effective in the management of whiplash injury.
… have demonstrated that manipulative treatment is more effective in the management of whiplash injury than conventional physiotherapy treatment.
Exercise therapy for patellofemoral pain syndrome (Review) Copyright © 2009 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Implications for practice
… limited evidence for the effectiveness of exercise therapy for PFPS.
… Open kinetic chain exercises and closed kinetic chain exercises are equally effective.
… Based on the limited evidence for effectiveness, physicians may consider exercise therapy for the treatment of PFPS.
Primary Care Physical Therapy in People With Fibromyalgia: Opportunities and Boundaries Within
a Monodisciplinary Setting. Jo Nijs, Kaisa Mannerkorpi, Filip Descheemaeker, Boudewijn Van Houdenhove. December 2010 Volume 90 Number 12 Physical Therapy.
… Primary care physical therapy for patients with FMS should include education, aerobic exercise, and strengthening exercise. For other treatment components such as passive treatments, activity management, and relaxation, less evidence currently is available to advocate their use in primary care
physical therapy. Superior results are to be expected when various treatment components are combined.
Heel Pain—Plantar Fasciitis: A Clinical Practice Guideline. Journal of Orthopaedic & Sports Physical Therapy, Volume 38, Number 4 April 2008.
… Dexamethasone 0.4% or acetic acid 5% delivered via iontophoresis can be used to provide short-term (2 to 4 weeks) pain relief and improved function
… There is minimal evidence to support the use of manual therapy and nerve mobilization procedures to provide short-term (1 to 3 months) pain relief and improved function.
… Calf muscle and/or plantar fascia-specific stretching can be used to provide short-term (2-4 months) pain relief and improvement in calf muscle flexibility.
… Calcaneal or low-Dye taping can be used to provide short-term (7-10 days) pain relief.
… Prefabricated or custom foot orthoses can be used to provide short-term (3 months) reduction in pain and improvement in function
… Night splints should be considered as an intervention for patients with symptoms greater than 6 months in duration.
Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association J Orthop Sports Phys Ther 2009;39(4):A1-A25. doi:10.2519/jospt.2009.0301
… Clinicians should consider the use of patient education to teach activity modification, exercise, weight reduction when overweight, and methods of unloading the arthritic joints.
… Functional, gait, and balance training, including the use of assistive devices such as canes, crutches, and walkers, can be used in patients with hip osteoarthritis to improve function associated with weight-bearing activities.
… Clinicians should consider the use of manual therapy procedures to provide short-term pain relief and improve hip mobility and function in patients with mild hip osteoarthritis.
… Clinicians should consider the use of flexibility, strengthening, and endurance exercises in patients with hip osteoarthritis.
Efficacy of exercise and ultrasound in patients with lumbar spinal stenosis: a prospective randomized controlled trial. Clin Rehabil. 2010 Jul;24(7):623-31. Epub 2010 Jun 8.
…The results of our study suggest that therapeutic exercises are effective for pain and disability in patients with lumbar spinal stenosis and that addition of ultrasound to exercise therapy lowers the analgesic intake substantially.
Knee Stability and Movement Coordination Impairments: Knee Ligament Sprain. Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther 2010;40(4):A1-A37. doi:10.2519/jospt.2010.0303
… Clinicians can consider using continuous passive motion in the immediate postoperative period to decrease postoperative pain.
… Early weight-bearing can be used for patients following ACL reconstruction without incurring detrimental effects on stability or function.
… The use of functional knee bracing appears to be more beneficial than not using a brace in patients with ACL deficiency.
… The use of immediate postoperative knee bracing appears to be no more beneficial than not using a brace in patients following ACL reconstruction.
… Conflicting evidence exists for the use of functional knee bracing in patients following ACL reconstruction.
… Knee bracing can be used for patients with acute posterior cruciate ligament (PCL) injuries, severe medial collateral ligament (MCL) injuries, or posterior lateral corner (PLC) injuries.
… Clinicians should consider the use of immediate mobilization following ACL reconstruction to increase range of motion, reduce pain, and limit adverse changes to soft tissue structures.
… Clinicians should consider the use of cryotherapy to reduce postoperative knee pain immediately post-ACL reconstruction.
… Clinicians should consider the use of exercises as part of the in-clinic program, supplemented by a prescribed home-based program supervised by a physical therapist in patients with knee stability and movement coordination impairments.
… Clinicians should consider the use of non–weight-bearing (open chain) exercises in conjunction with weight-bearing (closed chain) exercises in patients with knee stability and movement coordination impairments.
… Neuromuscular electrical stimulation can be used with patients following ACL reconstruction to increase quadriceps muscle strength.
… Clinicians should consider the use of neuromuscular training as a supplementary program to strength training in patients with knee stability and movement coordination impairments
… Rehabilitation that emphasizes early restoration of knee extension and early weight bearing activity appears safe for patients with ACL reconstruction. No evidence exists to determine the efficacy or safety of early return to sports.
… Clinicians should consider the use of an eccentric exercise ergometer in patients following ACL reconstruction to increase muscle strength and functional performance. Clinicians should consider the use of eccentric squat program in patients with PCL injury to increase muscle strength and functional performance.
Effects of spinal flexion and extension exercises on low-back pain and spinal mobility in chronic mechanical low-back pain patients. Elnaggar IM, Nordin M, Sheikhzadeh A, Parnianpour M, Kahanovitz N. Spine 1991; 16(8): 967-972
… Both the spinal flexion and the spinal extension exercises provided significant reduction in pain severity over time in persons with chronic mechanical low back pain.
… no statistically significant difference between the treatment groups.
… no statistically significant difference between the pretreatment sagittal mobility of both groups.
… Spinal flexion exercises led to greater sagittal plane mobility. Therefore, it was concluded that the nature of the spinal flexion exercises increased the sagittal mobility more effectively than did the spinal extension exercises.
Effects of low-level laser therapy and eccentric exercises in the treatment of recreational athletes with chronic achilles tendinopathy. Stergioulas A, Stergioula M, Aarskog R, Lopes-Martins RA, Bjordal JM. Am J Sports Med 2008; 36(5): 881-887
Low-level laser therapy with the parameters used in this trial seems to be a safe and effective method for more rapid recovery when combined with an eccentric exercise regimen. However, it must be stressed that using power densities below 100 mW/cm2 seems to be important for obtaining good results.
Effects of 904-nm low-level laser therapy in the management of lateral epicondylitis: a randomized controlled trial. Lam LK, Cheing GL. Photomed Laser Surg 2007; 25(2): 65-71
Nine sessions completed in 3 weeks of low-level laser therapy in combination of exercise is effective in relieving pain, increasing grip strength, and improving subjective rating of physical function when compared to the placebo group.
Exercises for mechanical neck disorders (Review) Copyright © 2009 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
… There is limited evidence of benefit for active range-of-motion exercises or a home exercise program for acute mechanical neck disorder including whiplash associated disorder.
… There is limited evidence that an eye-fixation program is beneficial for chronic mechanical neck disorder in the short term but not in the long term.
… There is unclear evidence of benefit for a stretching and strengthening program in chronic mechanical neck disorder.
… There is strong evidence of benefit favouring a multimodal care approach of exercise combined with
mobilisations or manipulations for subacute and chronic MND with or with headache in the short and long term.
Low level laser therapy (Classes I, II and III) for treating rheumatoid arthritis (Review) Copyright © 2010 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
… LLLT could be considered for short-term treatment for relief of pain and morning stiffness for RA patients, particularly since it has few side-effects.
The short-term efficacy of laser, brace, and ultrasound treatment in lateral epicondylitis: a prospective, randomized, controlled trial. J Hand Ther. 2008 Jan-Mar;21(1):63-7; quiz 68. Oken O, Kahraman Y, Ayhan F, Canpolat S, Yorgancioglu ZR, Oken OF. Ankara Education and Research Hospital, Department of Physical Medicine and Rehabilitation, Division of Hand Rehabilitation, Ankara, Turkey. okenoznur@yahoo.com
The aims of this study were to evaluate the effects of low-level laser therapy
(LLLT) and to compare these with the effects of brace or ultrasound (US)
treatment in tennis elbow. The study design used was a prospective and
randomized, controlled, single-blind trial. Fifty-eight outpatients with lateral
epicondylitis (9 men, 49 women) were included in the trial. The patients were
divided into three groups: 1) brace group-brace plus exercise, 2) ultrasound
group-US plus exercise, and 3) laser group-LLLT plus exercise. Patients in the
brace group used a lateral counterforce brace for three weeks, US plus hot pack … The results show that, in patients with lateral epicondylitis, a brace has a shorter beneficial effect than US and laser therapy in reducing pain, and that laser therapy is more effective than the brace and US treatment in improving grip strength.
Effectiveness of low-level laser therapy in temporomandibular joint disorders: a placebo-controlled study Fikackova H, Dostalova T, Navratil L, Klaschka J Photomed Laser Surg 2007; 25(4): 297-303
… Low level laser therapy (LLLT) was found to be effective for those suffering from chronic TMJ or myofascial pain. Eighty-one percent of the subjects receiving therapeutic levels of LLLT reported improvement.
Manipulation or Mobilisation for Neck Pain (Review) Copyright © 2010 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
… cervical manipulation produces similar pain relief, functional improvements, and patient satisfaction to mobilization
… cervical manipulation may provide short-term, but not long-term pain relief
… thoracic manipulation used alone or in combination with electrothermal or individualized physiotherapy treatments may improve pain and function
… cervical mobilisation is similar to manipulation or acupuncture for pain and function
… one mobilisation technique may be superior to another (that is, anterior-posterior mobilisation superior to transverse oscillatory and rotational mobilisation; ipsilateral posterioranterior or central posterior-anterior better then one of three random posterior-anterior mobilisations).
The efficacy of low-level laser therapy in supraspinatus tendinitis. Saunders L. Clin Rehabil 1995; 9(2): 126-134
… suggests that advice along with low-level laser therapy alleviated signs and symptoms of supraspinatus tendinitis, whereas the dummy laser did not.
CLINICAL GUIDELINES: Knee Pain and Mobility Impairments / Meniscal and Articular Cartilage Lesions
Clinical Practice Guidelines Linked to the International Classification of Functioning,
Disability, and Health from the Orthopaedic Section of the American Physical Therapy
Association. J David S. Logerstedt, PT, MA . Lynn Snyder-Mackler, PT, ScD. Richard C. Ritter, DPT. Michael J. Axe, MD. Orthop Sports Phys Ther. 2010:(_):A_-A_. doi:…………
… Clinicians may utilize early progressive knee motion following knee meniscal and articular cartilage surgery
… There are conflicting opinions regarding the best use of progressive weight bearing for patients with meniscal repairs or chondral lesions.
… Clinicians may utilize early progressive return to activity following knee meniscal repair surgery.
… Clinicians should consider a clinic-based program for patients following arthroscopic meniscectomy to increase quadriceps strength and functional performance.
… Clinicians can consider neuromuscular reeducation (functional exercise) for patients following meniscectomy to increase quadriceps endurance, hamstring strength, and functional performance.
… Neuromuscular electrical stimulation can be used with patients following meniscal or chondral injuries to increase quadriceps muscle strength
… Clinicians can use isokinetic strength training to increase quadriceps and hamstrings strength following meniscectomy.
Manipulative treatment vs. conventional physiotherapy treatment in whiplash injury: a randomized controlled trial. Fernandez-de-las-Penas C, Fernandez-Carnero J, Palomeque del Cerro L, Miangolarra-Page JC. J Whiplash Relat Dis 2004; 3(2): 73-90
… of this clinical trial have demonstrated that manipulative treatment is more effective in the management of whiplash injury than conventional physiotherapy treatment.
A benefit of spinal manipulation as adjunctive therapy for acute low-back pain: a stratified controlled trial. Hadler NM, Curtis P, Gillings DB, Stinnett S. Spine 1987; 12(7): 702-706
… subjects with a backache for 2-4 weeks prior to entry were afforded more rapid improvement if they were subjected to spinal manipulation.
Patellar taping increases vastus medialis oblique activity in the presence of patellofemoral pain. Christou EA. J Electromyogr Kinesiol 2004; 14(4): 495-504
The present study demonstrated that during a multi-joint movement patellar taping decreased pain, increased the activity of the VMO muscle, and decreased the activity of the VL muscle in individuals with patellofemoral pain syndrome (PFPS). Placebo taping conditions increased VMO activity and decreased pain similarly, it indirectly refutes the proposition that functional knee improvements aredue to a change in the patellar position. It is proposed that patellar taping, especially in a medial glide, may contribute positively to the rehabilitation of individuals with PFPS possibly due to an enhancedsupport of the medial ligaments of the patellofemoral joint and/or bymodulating pain via cutaneous stimulation.
Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther 2008;38(9):A1-A34. doi:10.2519/jospt.2008.0303
… should consider utilizing cervical manipulation and mobilization procedures, thrust and non-thrust, to reduce neck pain and headache. Combining cervical manipulation and mobilization with exercise is more effective for reducing neck pain, headache, and disability than manipulation and mobilization alone.
… Thoracic spine thrust manipulation can be used for patients with primary complaints of neck pain.
… Flexibility exercises can be used for patients with neck symptoms.
… Clinicians should consider the use of coordination, strengthening, and endurance exercises to reduce neck pain and headache.
… Specific repeated movements or procedures to promote centralization are not more beneficial in reducing disability when compared to other forms of interventions.
… Clinicians should consider the use of upper quarter and nerve mobilization procedures to reduce pain and disability in patients with neck and arm pain.
… Clinicians should consider the use of mechanical intermittent cervical traction, combined with other interventions such as manual therapy and strengthening exercises, for reducing pain and disability in patients with neck and neck-related arm pain.
… To improve recovery in patients with whiplash-associated disorder, clinicians should (1) educate the patient that early return to normal, non-provocative pre-accident activities is important, and (2) provide reassurance to the patient that good prognosis and full recovery commonly occurs.
The effectiveness of exercise in treating patellofemoral-pain syndrome. Loudon JK, Gajewski B, Goist-Foley HL, Loudon KL. J Sport Rehabil 2004; 13(4): 323-342
… structured, progressive exercise program appeared to reduce pain and improve function in subjects with patellofemoral pain syndrome.
… appears that a minimum of 5 visits for therapy is enough to reduce pain and improve function in patients with patellofemoral pain syndrome.
… critical that patients comply with their home exercise programs.
. J Hand Ther. 2008 Jan-Mar;21(1):63-7; quiz 68.
The short-term efficacy of laser, brace, and ultrasound treatment in lateral epicondylitis: a prospective, randomized, controlled trial. Oken O, Kahraman Y, Ayhan F, Canpolat S, Yorgancioglu ZR, Oken OF. Ankara Education and Research Hospital, Department of Physical Medicine and Rehabilitation, Division of Hand Rehabilitation, Ankara, Turkey. okenoznur@yahoo.com
Erratum in: J Hand Ther. 2008 Jul-Sep;21(3):303.
… results show that, in patients with lateral epicondylitis, a brace has a shorter
beneficial effect than US and laser therapy in reducing pain
… laser therapy is more effective than the brace and US treatment in improving grip strength.
Manipulation in the treatment of acute low back pain. Morton JE. J Man Manipulative Ther 1999; 7(4): 182-189
… definite inference that patients who receive manipulation with exercises for acute low back pain of mechanical origin will improve more and faster than patients who receive an exercise program alone.
Patellar taping increases vastus medialis oblique activity in the presence of patellofemoral pain. Christou EA. J Electromyogr Kinesiol 2004; 14(4): 495-504
… during a multi-joint movement patellar taping decreased pain, increased the activity of the VMO muscle, and decreased the activity of the VL muscle in individuals with patellofemoral pain syndrome (PFPS).
Surface neuromuscular electrical stimulation for quadriceps strengthening pre and post total knee replacement (Review) Copyright © 2010 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
… we are uncertain whether electrical stimulation affects thigh muscle strength before and after knee replacement surgery because of the very low quality of the evidence.
(Leon notes that other studies done have stated that “in a normally innervated and healthy muscle” the “Russian” electrical stimulation cannot elicit a muscle contraction any stronger than the maximum voluntary contraction generated by the individual. However, we are not discussing muscle satisfying the definition of “normally innervated and healthy”. The muscle we are discussing is inhibited due to injury (surgery) to the knee and having had a tourniquet on it during surgery. The statement by Cochrane is accurate in that the quality of the evidence is not good, therefore any conclusions reached would need to be unclear.)
Therapeutic ultrasound for acute ankle sprains (Review) Copyright © 2010 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
… The extent and quality of the available evidence for the effects of ultrasound therapy for acute ankle sprains is limited
… few trials are available and no conclusions can be made regarding any optimal dosage schedule for ultrasound therapy, and whether such a schedule would improve the reported lack of effectiveness of ultrasound for ankle sprains.
Therapeutic ultrasound for treating patellofemoral pain syndrome (Review) Copyright © 2009 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
… Ultrasound therapy was not shown to have a clinically important effect on pain relief for people with patellofemoral pain syndrome.
… conclusions are limited by the poor reporting of the therapeutic application of the ultrasound and low methodological quality of the one trial included.
… conclusions can be drawn concerning the use, or non-use, of ultrasound for treating patellofemoral pain syndrome. More well-designed studies are needed.
Ultrasound treatment for treating the carpal tunnel syndrome: randomised “sham” controlled trial. Ebenbichler GR, Resch KL, Nicolakis P, Wiesinger GF, Uhl F, Ghanem AH, Fialka V. BMJ. 1998 Mar 7;316(7133):731-5. Department of Physical Medicine and Rehabilitation, University of Vienna, Austria.
… suggest there are satisfying short to medium term effects due to ultrasound treatment in patients with mild to moderate idiopathic carpal tunnel syndrome. Findings need to be confirmed, and ultrasound treatment will have to be compared with standard conservative and invasive treatment options.
Effects of ultrasound therapy on calcificated tendinitis of the shoulder. Shomoto K, Takatori K, Morishita S, Nagino K, Yamamoto W, Shimohira T, Shimada T. J Jpn Phys Ther Assoc 2002; 5(1): 7-11
… ultrasound therapy used along with therapeutic exercises had better results in decreasing the size of the calcification and decreasing pain during active movement than the treatment of therapeutic exercises alone. In the treatment group, all patients showed a decrease in calcification size during the treatment while in the control group many saw no signs of improvement or worsening of the condition. All patients that had a complete resolution of the calcification experienced no pain at the end of the study.
J Med Assoc Thai. 2004 Sep;87 Suppl 2:S100-6. Effect of ultrasound thermotherapy in mild to moderate carpal tunnel syndrome. Piravej K, Boonhong J. Department of Rehabilitation Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand.
… therapeutic efficacy of low intensity ultrasound thermotherapy was satisfied for mild to moderate CTS. However, the electrophysiological changes after ultrasound treatment need further investigation.
Low-intensity pulsed ultrasound increases bone volume, osteoid thickness and mineral apposition rate in the area of fracture healing in patients with a delayed union of the osteotomized fibula. Bone 2008 Aug;43(2):348-54. Rutten Sjoerd S, Nolte Peter A PA, Korstjens Clara M CM, van Duin Marion A MA, Klein-Nulend Jenneke J, Rutten S, Nolte P, Korstjens C, van Duin M, Klein-Nulend J. Department of Oral Cell Biology, ACTA-Universiteit van Amsterdam and Vrije Universiteit, Research Institute MOVE, Amsterdam, The Netherlands.
… results suggest that LIPUS accelerates clinical fracture healing of delayed unions of the fibula by increasing osteoid thickness, mineral apposition rate, and bone volume, indicating increased osteoblast activity, at the front of new bony callus formation. Improved stability and/or increased blood flow, but probably not increased angiogenesis, might explain the differences in ossification modes between LIPUS-treated delayed unions and untreated controls.
Short-term Effects of High-Intensity Laser Therapy Versus Ultrasound Therapy in the Treatment of People With Subacromial Impingement Syndrome: A Randomized Clinical Trial
… diagnosed with SAIS showed greater reduction in pain and improvement in articular movement functionality and muscle strength of the affected shoulder after 10 treatment sessions of HILT than did participants receiving US therapy over a period of 2 consecutive weeks.
Low-intensity pulsed ultrasound in the treatment of nonunions. J Trauma 2001 Oct;51(4):693-702; discussion 702-3. Nolte P A PA, van der Krans A A, Patka P P, Janssen I M IM, Ryaby J P JP, Albers G. Department of Orthopaedics, Academic Medical Center, University of Amsterdam, The Netherlands. panolte@knmg.nl
… Noninvasive ultrasound therapy can be useful in the treatment of challenging, established nonunions.
A double-blind trial of clinical effects of therapeutic ultrasound in knee osteoarthritis. Ozgonenel L, Aytekin E, Durmusoglu G. Ultrasound Med Biol 2009; 35(1): 44-49
… Both groups showed improvements in overall WOMAC, VAS, and walking test when compared to pre and post treatment.
… ultrasound group showed greater percentage improvements in the total WOMAC scores (and in each of the scales).
… Walking time measurements only showed statistically significant improvements for the ultrasound group.
Low-intensity pulsed ultrasound and pulsed electromagnetic field in the treatment of tibial fractures: a systematic review. J Athl Train 2007 Oct;42(4):530-5. Walker Nicol A NA, Denegar Craig R CR, Preische Jody J. Pennsylvania State University, 146 Recreation Building, University Park, PA 16802-5702, USA. nikkiwerner@yahoo.com
… evidence suggests that LIPUS may speed healing of acute tibial fractures. Comparison studies of these modalities are needed to guide treatment of fractures sustained by athletic individuals.
Low-intensity pulsed ultrasound on tendon healing: a study of the effect of treatment duration and treatment initiation. Am J Sports Med 2008 Sep;36(9):1742-9. Fu Sai-Chuen SC, Shum Wai-Ting WT, Hung Leung-Kim LK, Wong Margaret Wan-Nar MW, Qin Ling L, Chan Kai-Ming KM. Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, China.
… Low-intensity pulsed ultrasound promoted restoration of mechanical strength and collagen alignment in healing tendons only when applied at early healing stages.
… findings indicate that low-intensity pulsed ultrasound may be an effective treatment to reduce tendon donor site morbidity.