Common neuromusculoskeletal disorders in the workplace W. Shane Journeay, PhD, MD, MPH, FRCPC, BC-OEM
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1 Common neuromusculoskeletal disorders in the workplace W. Shane Journeay, PhD, MD, MPH, FRCPC, BC-OEM OEMAC Calgary September 23, 2018
2 OBJECTIVES 1. To name key diagnoses of neuromusculoskeletal conditions seen in the workplace 2. To describe the risk factors and mechanisms for common work-related neuromusculoskeletal conditions 3. To list key principles of management, rehabilitation and return to work in neuromusculoskeletal disorders
3 Two common disorders Shoulder Spine Other
4 Approach and causality Mechanism Timeline of injury (Acute / chronic) Type of occupation (dynamic, static postures) Biomechanics Medical history Epidemiology
5 Working towards a diagnosis Bone - fracture, contusion Muscle strain, tear Tendon tendinosis/-opathy, tear Bursa - bursitis Ligament sprain Joint arthritis Nerve entrapment, radiculopathy, PN
6 Shoulder History / Mechanism Insidious onset vs Traumatic Outstretch arm, pulling, reaching Static postures Exacerbating and relieving factors
7 Examination Posture Active ROM Passive ROM Deformity subluxed? A.C. deformity? Effusion?
8 ROTATOR CUFF DISORDERS Subacromial Bursitis Inflammation of bursa Supraspinatus Tendinitis Inflammation of tendon Rotator Cuff Tears Degenerative/traumatic Impingement One possible cause for pain
9 Supraspinatus Empty Can test Jobe s test Jain et al. PMR 2013
10 Subscapularis Belly Press off Jain et al. PMR 2013
11 Bicipital tendon Speed s Test Jain et al. PMR 2013
12 Impingement Neer Sign Jain et al. PMR 2013
13 Management Diagnosis? Structure injured Soft tissue? Rest, ROM, Ice, NSAID Investigation Ultrasound vs MRI Rehabilitation May require focused rehab depending on job tasks Otherwise pain management and maintain ROM
14 Question 1 A 50-year-old man sustains a left shoulder injury after falling from a ladder. A physical examination test to examine for this shoulder injury is found. What is the most likely diagnosis? 1. SLAP tear 2. Supraspinatus tear 3. Infraspinatus tear 4. Teres minor tear 5. Subscapularis tear OrthoBullets
15 Answer A 50-year-old man sustains a left shoulder injury after falling from a motorcycle. A physical examination test to examine for this shoulder injury is found. What is the most likely diagnosis? 1. SLAP tear 2. Supraspinatus tear 3. Infraspinatus tear 4. Teres minor tear 5. Subscapularis tear OrthoBullets
16 Answer Belly-press and Lift-off maneuvers OrthoBullets
17 Question 2 Rotator cuff tears (full thickness and partial thickness) in asymptomatic individuals are seen on MRI or ultrasound in what percentage of patients over the age of 60? % % % % % OrthoBullets
18 Answer Rotator cuff tears (full thickness and partial thickness) in asymptomatic individuals are seen on MRI or ultrasound in what percentage of patients over the age of 60? % % % % % OrthoBullets
19 Answer The prevalence of asymptomatic rotator cuff tears diagnosed with MRI or ultrasound is quite high, with most studies noting tears in 30-54% of patients over the age of 60. OrthoBullets
20 Spine and Back pain
21 Acute low back pain Lumbar strain with or without radicular symptoms Common Lifting New workers
22 History Red flags imaging Medical history & Mechanism Lifting Twisting Fall Pain referral pattern (LBP +/- radicular symptoms) Banding Lumbago Radicular pain
23 Red Flags
24 Examination Posture Palpation/percussion -?Spasm ROM Neurological exam! Bulk, Tone, Power, Reflexes, Sensation Straight leg raise, Slump test, Femoral stretch
25 Case 1 Hx: 54M construction worker presents with back pain radiating down to the left ankle after lifting 75lb cement blocks. Severe pain with onset x 24h. No hx of cancer, diabetes. No history of neurogenic claudication. B/B normal. Tried NSAIDs. O/E: antalgic gait. Forward flexed. Can t get comfortable. SLR positive. 4+/5 left dorsiflexion. MRI posterolateral disc protrusion compressing exiting L4 nerve root on left
26 Lumbar Radiculopathy Rule of thirds 1/3 traumatic events (I.e.heavy lifting) 1/3 routine activity (walking, making bed) 1/3 non-specific (I.e. arising from chair, at rest)
27 Lumbar disc herniation Deyo & Mirza NEJM 2016
28 Common Lumbar Dermatomes Deyo & Mirza NEJM 2016
29 Gluteus medius & Longissismus (can mimic radiculopathy) pseudo-sciatica Triggerpoints.net
30 Management & Rehabilitation Monitor + Conservative modalities Counsel on recovery and red flags If persistent pain, loss of motor function obtain imaging, or red flags Regular activity +/- PT Epidural If completed early can improve pain sooner but after 6-12 months everyone is the same Ergonomics
31 Case 2 Hx: 25M with back pain since age 21. Began working for moving company and flared his pain. Pain is located in left low back, deep. No radicular pain. No B/B dysfunction. No leg weakness. No red flags. No sensory changes. <30 mins of morning stiffness. Better with light activity. Worse with long day of work or heavy work out. No stigmata of rheumatological disease. His FHx is non-contributory. Did report wrenching his low back diving at age 21. O/E: Neuro intact. Full flexion and extension. Lateral bending to the right can only reach 3 cm proximal to fibular head and the left can reach fibular head. Point tenderness over left quadratus lumborum that reproduced his pain. X-ray and SI joint views- normal. HLA B27 negative. Inflammatory markers normal.
32 Myofascial pain / Lumbar strain Myofascial low back pain: may have trigger points include the iliocostalis lumborum, longissimus thoracis, multifidus,the quadratus lumborum and gluteus medius are the most frequently involved Triggerpoints.net
33 Role of Electrodiagnostics (EMG/NCS) Localizes peripheral nerve lesions Tests the integrity of the motor units and sensory nerves Can determine neurophysiology of multiple nerves or myotomes and chronicity Does not say what is causing the problem Often concludes Suggest MRI of L/S spine With good physical exam and MRI; little role for EDx Caveats - neurorecovery and surgical planning
34 Summary Shoulder injuries are common with the majority comprising softtissue injury. Careful history and exam can narrow the differential and guide management Management is generally conservative Back pain is not always simple back pain - Neurology and function are a priority Many rehabilitation strategies ranging from pain management, exercise and focused rehabilitation strategies Questions & Discussion? shane.journeay@utoronto.ca wsj818@mail.harvard.edu
35 References Jain et al. PM&R 5:45-56, 2013 Deyo & Mirza NEJM 374: , 2016 Carette & Fehlings NEJM 353:4, , 2005 Orthobullets Triggerpoints.net
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