1. The Assessment and Management of WRULD`s Jonathan Daniel MCSP HCPC Occupational Health Physiotherapist (Director)
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2. 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
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3. 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)
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4. 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)
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5. 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?
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6. 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
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7. 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?
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8. 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.
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9. WRULD`s Q:
How can OHNs/advisors differentiate between the different types of WRULD`s? A:
Subjective history and basic assessment
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10. 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!
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11. History Taking is Key
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12. Is this a WRULD as he was out on a works do?!
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13. Top 5 WRULD`S Shoulder Impingement/ rotator cuff pathologies
Tennis elbow
Carpal tunnel
Wrist tenosynovitis
Frozen shoulder
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14. Shoulder Impingement definition
Inflammation of the soft tissue structures around the glenohumeral joint.
The main structures are:
The rotator cuff
Subacromial bursae
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15. Shoulder Impingement definition
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16. 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
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17. 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.
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18. Shoulder impingement test Hawkins Kennedy
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19. 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.
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20. Management pathway for Shoulder impingement
Self management
Physiotherapy
? Steroid injection
Referral to orthopaedic consultant if persistent
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21. 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)
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22. Tennis Elbow
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23. 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.
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24. 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
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25. 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
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26. Carpal Tunnel
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27. 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
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28. Diagnosing Carpal Tunnel
There are several tests you can do to determine if someone has carpal tunnel syndrome.
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29. Phalen’s test - press the backs of your hands together for a minute to see if this causes numbness or tingling.
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30. Tapping the median nerve causes tingling in the fingers.
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31. 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
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32. 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
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33. Wrist Tenosynovitis
De Quervain's tenosynovitis - a painful condition affecting the tendons on the thumb side the wrist.
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34. 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.
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35. Finklestein’s test Grasp the thumb under the fingers and bend the wrist down
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36. Self Management Stretches Ice Self Massage
Move the shoulder wrist and hand through a full range of movement 2-3 times daily
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37. Treatment pathway for Wrist Tenosynovitis
Self Management
Physiotherapy
Steroid Injection
Referral to Orthopaedic consultant.
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38. 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
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39. 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
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40. 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)
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41. 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.
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42. The Brachial plexus
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43. 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.
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44. 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
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45. Treatment pathway for Upper Limb Disorders
Self management
G.P. for medication
Physiotherapy
? Steroid Injection for problematic cases
Consultant referral if persistent ( Scans, Xray)
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46. 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
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47. 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
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48. Questions Please??
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