The Assessment and Management of WRULD`s Jonathan Daniel MCSP HCPC Occupational Health Physiotherapist (Director) Copyright FitBack 2014

What will we be looking at? WRULD`s Vs ULD`s? Possible causes of WRULD`s Introducing the top 5 ULD`s Assessment and management of WRULD`s Case study Copyright FitBack 2014

ULD`s Vs WRULD`s ? WRULD`s : Somewhat vague term under which a large variety of conditions and symptoms are classed. Those conditions with a specific recognised medical diagnosis (recognised clinical tests and clear-cut associated symptoms) Those whose symptoms are more of a 'diffuse' nature which lack a clear-cut diagnosis. (Tingling , pins needles, numbness, heaviness) Copyright FitBack 2014

What are ULDs? Conditions which affect the muscles, tendons, ligaments, nerves or other soft tissues and joints in the upper limbs such as the neck, shoulders, arms, wrists, hands and fingers. (HSE 2013) Copyright FitBack 2014

Q: Is an upper limb injury caused outside of work deemed a WRULD if it is affecting their performance at work or aggravated by work? Copyright FitBack 2014

Possible Causes of WRULD`s In The Workplace Repetitive work Uncomfortable working postures Sustained or excessive force Carrying out tasks for long periods without suitable rest breaks Poor working environment Copyright FitBack 2014

Your current processes? How do you currently assess and manage your patients with WRULD`s What are the aims of your assessment? What are you hoping to use the findings from your assessment for? Copyright FitBack 2014

Primary care givers Given the current lengths of NHS waiting lists, as occupational health professionals in the workplace we are often the primary care givers. Therefore it is vital that we give the right type of care at the earliest possible opportunity. This will help to prevent common health problems resulting in chronic disability. Copyright FitBack 2014

WRULD`s Q: How can OHNs/advisors differentiate between the different types of WRULD`s? A: Subjective history and basic assessment Copyright FitBack 2014

History Taking is Key Careful questioning is vital to help diagnose Patients can be poor historians! Very often there is no one incident or recollection of injury Often there is a slow progression of symptoms Symptoms often don`t tie in with the pathology…….don`t get caught out! Copyright FitBack 2014

History Taking is Key Copyright FitBack 2014

Is this a WRULD as he was out on a works do?! Copyright FitBack 2014

Top 5 WRULD`S Shoulder Impingement/ rotator cuff pathologies Tennis elbow Carpal tunnel Wrist tenosynovitis Frozen shoulder Copyright FitBack 2014

Shoulder Impingement definition Inflammation of the soft tissue structures around the glenohumeral joint. The main structures are: The rotator cuff Subacromial bursae Copyright FitBack 2014

Shoulder Impingement definition Copyright FitBack 2014

Symptoms of shoulder impingement Pain on lifting the arm above the head Pain while sleeping on the affected side. The outer side of the shoulder may become swollen and may at times feel warm. Weakness of the shoulder muscles Stiffness of the shoulder and lack of certain movements Difficulty Fastening Bra ( women!) Putting on coat Reaching for seatbelt Copyright FitBack 2014

What structures are affected in impingement? The rotator cuff ( Supraspinatus muscle) These are the 4 main muscles responsible for holding and moving the arm in the socket: The Bursae These are sacks of fluid underneath the muscles to help them run smoothly. Copyright FitBack 2014

Shoulder impingement test Hawkins Kennedy Copyright FitBack 2014

Teaching self management of shoulder impingement Correct the position of the shoulder Keep the shoulder moving but do not push through pain. Work the arm at a waist level initially. Keep the rest of the arm and hand functioning normally. Copyright FitBack 2014

Management pathway for Shoulder impingement Self management Physiotherapy ? Steroid injection Referral to orthopaedic consultant if persistent Copyright FitBack 2014

Tennis Elbow Definition: Tennis elbow - an inflammation of several structures of the elbow: Muscles, tendons, bursa, periosteum, and epicondyle (Often caused by repetitive movements involving an extended wrist. Screw driver, tennis) Copyright FitBack 2014

Tennis Elbow Copyright FitBack 2014

Clinical Signs of Tennis Elbow Dull constant pain and possible heat on the outer part of elbow Point of tenderness over the lateral epicondyle on the outside of the elbow. Gripping with the hand/shaking hands painful. Activities that use the muscles that extend the wrist (e.g. pouring movements, lifting with the palm down) are characteristically painful. Morning elbow stiffness. Copyright FitBack 2014

Assessment of Tennis Elbow Question carefully history of problem Difficulty opening jars, shaking hands Possible causes? Palpation on outside of elbow is very tender! Resisted wrist extension is weak and painful Copyright FitBack 2014

Carpal tunnel Affects the median nerve, which passes through the carpal tunnel in the wrist and controls the movement of the hand. The three main symptoms are: tingling , numbness, pain These symptoms occur in: the thumb, the index finger, the middle finger, half of the ring finger Copyright FitBack 2014

Carpal Tunnel Copyright FitBack 2014

Who gets carpal tunnel? Women are 3x more likely than men to get carpal tunnel syndrome. Certain conditions increase risk: Diabetes and rheumatoid arthritis Pregnancy Sprain or fracture of the wrist Copyright FitBack 2014

Diagnosing Carpal Tunnel There are several tests you can do to determine if someone has carpal tunnel syndrome. Copyright FitBack 2014

Phalen’s test - press the backs of your hands together for a minute to see if this causes numbness or tingling. Copyright FitBack 2014

Tapping the median nerve causes tingling in the fingers. Copyright FitBack 2014

Assessing Carpal Tunnel Aggravating/ easing factors Check neck movements!!! Ask about neck stiffness Ask about neck pain Headaches?...tension in shoulders? Possible diagnostics ( nerve conduction studies) Always recommend Physiotherapy before diagnostics Copyright FitBack 2014

Teaching self management of Carpal Tunnel Improve your posture Reduce the pressure on your carpal tunnel Keep the hand and the arm moving normally Move the wrist, elbow, shoulder, hand and neck through a full range of movement 2-3 times daily Copyright FitBack 2014

Wrist Tenosynovitis De Quervain's tenosynovitis - a painful condition affecting the tendons on the thumb side the wrist. Copyright FitBack 2014

Symptoms Pain on the thumb side of the wrist Swelling Difficulty moving the thumb and wrist when on doing activities that involve grasping or pinching A "sticking" or "stop-and-go" sensation in the thumb when trying to move it. Copyright FitBack 2014

Finklestein’s test Grasp the thumb under the fingers and bend the wrist down Copyright FitBack 2014

Self Management Stretches Ice Self Massage Move the shoulder wrist and hand through a full range of movement 2-3 times daily Copyright FitBack 2014

Treatment pathway for Wrist Tenosynovitis Self Management Physiotherapy Steroid Injection Referral to Orthopaedic consultant. Copyright FitBack 2014

Frozen Shoulder Frozen shoulder- (adhesive capsulitis) a condition where a shoulder becomes painful and stiff. It is thought to be due to scar-like tissue forming in the shoulder capsule. Without treatment, symptoms usually resolve but this may take up to 2-3 years. Affects 3% adults Women> Men More common over age of 50 years Copyright FitBack 2014

Frozen Shoulder contd Signs/Symptoms: Shoulder flexion , abduction and rotation restricted +++ Cant get hand behind back/ or brush hair Will hitch their shoulder when lifting arm up Copyright FitBack 2014

Managing ULDs in the Workplace Assess the risks – this means looking around your workplace to see which jobs may cause harm Decide how likely it is that harm will occur, ie the level of risk, and what to do about it; Change the way work is organised to help reduce risk; Help sufferers when they come back to work. (HSE 2013) Copyright FitBack 2014

What if the individual upper limb tests are negative? Symptoms may be coming from higher up the chain - Typically at the cervical spine. If you suspect a neck problem eg if individual is complaining of pins and needles or altered sensation. This requires early referral to physio. Much can be done for neck, shoulder wrist and hand problems through the correction of posture. Copyright FitBack 2014

The Brachial plexus Copyright FitBack 2014

More diffuse symptoms More diffuse symptoms / non specific symptoms will need further investigating/ assessment Eg: Aches, pain, tingling, cramps, numbness, heaviness. Referral to a Physiotherapist is vital. Copyright FitBack 2014

Self management of Upper limb disorders Refer to self management leaflet Ice when acute, heat for general muscular tension ? medications Keep surrounding joints moving regularly Correct posture Relaxation for tension related problems Copyright FitBack 2014

Treatment pathway for Upper Limb Disorders Self management G.P. for medication Physiotherapy ? Steroid Injection for problematic cases Consultant referral if persistent ( Scans, Xray) Copyright FitBack 2014

Summary Early intervention produces the best and fastest results. Most effective treatment for WRULD`s lies in a combination of : hands-on techniques, exercises, relaxation, good workstation ergonomics advice on posture work pacing Copyright FitBack 2014

Case Study 25 year old female Food production line worker. Long shifts, static postures Referred to Physiotherapy post carpal tunnel release. No improvement in Symptoms post op Had bilateral tingling in wrists and fingers No one had examined her neck movements prior to surgery! Very stiff neck Particularly extension and rotation. Upper limb nerve tension problems++ Treatment= mobilised neck and given neural stretches Symptoms improved 80% in 2 sessions. Regular mobility ex`s for neck Copyright FitBack 2014

Questions Please?? Copyright FitBack 2014