Laura Jones Chism, OTS Spalding University January 24, 2014 Effective Interventions for the Rehabilitation of Upper Extremity Cumulative Trauma Disorders Laura Jones Chism, OTS Spalding University January 24, 2014

Practice Problem Individuals with cumulative trauma disorders are at a greater risk for significant limitations in their ability to independently function within their home, jobs, and community. Many individuals present with debilitating symptoms such as pain, weakness, and swelling. According to the Bureau of Labor Statistics, workers who sustained CTDs required a median of 12 days to recuperate before returning to work repetitive strain injuries are the nation's most common and costly occupational health problem, affecting hundreds of thousands of American workers and costing more than $20 billion a year in workers' compensation costs.

What are cumulative trauma disorders (CTDs)? Work-related musculoskeletal disorders Repetitive strain injuries Overuse syndrome What are cumulative trauma disorders (CTDs)? A cumulative trauma disorder is a condition where part of the body is injured by repeatedly overusing or causing trauma when the body part is called on to work harder, stretch farther, impact more directly or otherwise function at a greater level than it is prepared for. *In 2012, CTDs accounted for 34% of all workplace injuries and illnesses requiring absence from work. CTDs are injuries of the musculoskeletal system which includes joints, muscles, tendons, ligaments, nerves, and blood vessels.

Risk factors for CTDs • repetitive motions • forceful exertions • awkward postures • static postures • mechanical compression of soft tissues in the hand • fast movement of body parts • vibration, especially in cold conditions • lack of sufficient recovery time • repetitive motions • forceful exertions - pulling, pushing, lifting, and gripping • awkward postures - body positions that are not the natural resting positions • static postures - body positions held without moving • mechanical compression of soft tissues in the hand against edges or ridges - using tools or objects which press against the palm • fast movement of body parts • vibration, especially in cold conditions • lack of sufficient recovery time (rest breaks, days off)

How CTDs affect everyday occupational performance ADLs dressing, bathing, feeding IADLs cooking, caring for others, typing on the computer, driving Work job performance Leisure hobbies such as sewing or playing golf

Level IIB Fieldwork experience VAMC in Lexington, KY *carpal tunnel syndrome (CTS) *lateral epicondylitis How are CTDs diagnosed? *patient symptom reports *provocative testing *EMG/Nerve conduction study *MRI *clinical exam (physician diagnoses) VA population for CTD: outpatients (seen roughly for 45 minutes every 4-6 weeks for followup) – veterans (men, women) ages I saw 27-86 Cumulative trauma disorders primarily affect the upper extremities and include such disorders as carpal tunnel syndrome, wrist tendonitis, ulnar nerve entrapment, epicondylitis, shoulder tendonitis, and hand-arm vibration syndrome.

Level IIB Fieldwork experience (continued) Treatments: *pre-fabricated splinting *retrograde massage *Fluidotherapy *tendon and nerve gliding exercises *patient education (activity modification, ergonomics) *adaptive equipment for ADLs if needed

Research Process Do client-centered, tailored therapies make a difference? What interventions reduce symptoms the most? Focus Question “What occupational therapy interventions are effective in the rehabilitation of individuals with cumulative trauma disorders of the upper extremity?” What about DPAMs?

Research Process Database sources: AJOT, Medline, EBSCO Articles within the past 5 years assessing: Exclusive interventions or combinations of the following: cryotherapy, exercises, ultrasound*, neuromuscular electrical stimulation (NMES)*, tendon and nerve gliding exercises, Madenci Hand Massage Technique (MHMT), ischemic compression therapy Diagnoses: Carpal tunnel syndrome and lateral epicondylitis Outcome Measures assessing: Grip strength improvements, pain reduction, increased functional activities *Deep Physical Agent Modality (DPAM)

What does the evidence say? Low-level frequency electrical stimulation used as a preparatory method for meaningful activities showed superior results for pain reduction, improved grip strength, and improved functional performance One study concluded that 100% of participants maintained improved function and 83% remained pain-free for at least six months post treatment. The combination of tendon and nerve gliding exercises, ultrasound, and splinting resulted in significant improvements The above treatment combination was significantly effective for up to 8 weeks after the treatment. Majority of studies strengths of our study were strong in that they included the prospective, randomized design, the use of valid, standard measures, and the evaluation of the functional status of patients. Many studies used valid and reliable outcome measures

What does the evidence say? (continued) Ultrasound therapy showed significant improvements in functional performance scores, VAS pain levels, and grip strength Pain at rest and in motion was significantly reduced following ultrasound therapy with carryover into 3 months post therapy Participants reported a preference toward certain therapies due to ease of use, effectiveness in symptom reduction, and overall comfort Clients with CTDs made strong, positive gains in functional measures following client-centered OT services The COPM was the most sensitive to client change

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

Clinical bottom line Improved quality of life Improved grip strength Decreased pain Improved performance and independence in functional activities Return to work! Patients are likely to continue program

What does this mean for OT? Validates OT for treatment of UE CTD Use DPAMs and conservative treatments as preparation for or concurrently with purposeful and occupation-based activities that enhance engagement in occupation Challenge: hand clinics typically treat with a more biomechanical approach using interventions such as paraffin bath, theraputty, etc Encourage client contribution in goal setting for improvements in meaningful ADLS/IADLS Choose tailored interventions based on the unique needs, preferences, and goals of patients AOTA Centennial Vision evidence based challenges OT's face in providing occupation-based treatment in hand settings; you are doing this but give an example of a typical CTD patient and how he/she would be treated traditionally (paraffin, putty etc.) and how an OT could blend in occupation-based tx.

Thank you! What questions do you have? Laura Chism, OTS laurajchism@gmail.com •Stories/comments relating to your family or clients? •Did you find any of this information or research surprising?