Cumulative Trauma

Disorders
 Cumulative trauma disorder
 Repetitive strain injury
 Work related musculoskeletal disorder
 Synonymous generic terms
 Repetitive strain injuries (RSI)
 Cumulative trauma disorders
 Occupational cervicobrachial disorders
 Overuse syndrome
 Repetitive motion injuries
 The US department of Labor defines
WMSD as injuries or disorders of the
muscles ,nerves, tendons, joints, cartilage
and spinal discs associated with exposure
to risk factors in the work place
 Dose response relationships between
work task demands are not clearly defined
 The number of cases are increasing
because of the increased awareness of
the work related nature of these conditions

 There is considerable confusion and

controversy surrounding WMSD’s
 Injury rates for work related
musculoskeletal disorders are high
 Statistics from the occupational health and
safety administration (OSHA) suggests
that WMSD accounts for 50% of all
occupational injuries
 Epidemiology
 Feurstein et al –cross sectional study on
WMSD’s in 1994 and economic costs
 Conclusions :-CTS and hand wrist
tendinitis most prevalent
 Leclerc at al 2001 prospective 3 year
study of UE WMSD and musculoskeletal
symptoms
 Conclusion:-combination of risk factors
responsible including biomechanical
psychosocial and individual characteristics
 Hagberg et al 2002 cross sectional survey
of prevalence of WMSD’s symptoms and
loss of productivity in computer users
 Conclusion:-UE WMSD prevalent among
computer users with impact on productivity
 Two main groups of disorders are
identified
1.Specific soft tissue syndrome
2.Non specific disorders
 Teninitis or tenosynovitis
 Extensors
 Flexors
 Rotator cuff injuries
 Lateral epicondylitis
Nerve compression syndromes
 Cervical radiculopathy
 Thoracic outlet syndrome
 Cubital tunnel syndrome
 Anterior interosseus syndrome
 Posterior interosseus syndrome
 Pronator teres syndrome
 Carpal tunnel syndrome
 Guyon’s canal syndrome
 Pain syndromes
 Reflex sympathetic dystrophy
 Myofascial pain syndrome
 Fibrositis
 Fibromyalgia
 Others
 Vibration white finger
 Arthritis
 Risk factors
 Repetition
 Force
 Awkward postures
 Static postures
 Contact stress
 Temperature extremes
 Vibration
 Psycho-social
 Repetition :when the same or the similar
movements are performed frequently
Cycle time of 30 seconds
 Cross-sectional study of the
relationship between repetitive work
and the prevalence of upper limb
musculoskeletal disorders.

Am Journal of Ind Med,1999

 This study examined the relationship of
repetitive work and other physical
stressors to prevalence of upper limb
discomfort, tendinitis, and carpal tunnel
syndrome
 Repetitiveness of work was found to be
significantly associated with prevalence of
reported discomfort in the wrist, hand, or
fingers (odds ratio (OR) = 1.17 per unit of
repetition; OR = 2.45 for high vs. low
repetition), tendinitis in the distal upper
extremity (OR = 1.23 per unit of repetition;
OR = 3.23 for high vs. low repetition), and
symptoms consistent with carpal tunnel
syndrome (OR = 1.16 per unit of repetition;
OR = 2.32 for high vs. low repetition).
 Understanding work related
musculoskeletal pain: does repetitive
work cause stress symptoms?

Occup Environ Med,2005

Awkward Posture
 Working with the hand(s) above the head,
or the elbow(s) above the shoulder, more
than 2 hours total per day
 Working with the neck or back bent more
than 30 degrees (without support and
without the ability to vary posture) more
than 2 hours total per day
 Abnormal posture
or position

Decrease in muscle Increase in nerve

length tension
Increase in muscle SCM Carpal tunnel
length Serratus anterior Cubital tunnel
Middle trapezius Pronator teres Median fore arm
Lower trapezius Scalenes Radial sensory
Pectoralis minor Brachial plexus

Muscle weakness Muscle overuse

Middle trapezius Upper trapezius
Lower trapezius levatorscapulae
Serratus anterior
High Hand Force
 Pinching an unsupported object(s)
weighing 2 or more pounds per hand, or
pinching with a force of 4 or more pounds
per hand, more than 2 hours total per day
(comparable to pinching half a ream of
paper)
Highly Repetitive Motion
Repeating the same motion with the neck,
shoulders, elbows, wrists, or hands
(excluding keying activities) with little or
no variation every few seconds more than
2 hours total per day
Performing intensive keying more than 4
hours total per day
 Repeated Impact
Using the hand (heel/base of palm) or
knee as a hammer more than 10 times per
hour more than 2 hours total per day
Heavy, Frequent or Awkward Lifting
 Lifting objects weighing more than 75
pounds once per day or more than 55
pounds more than 10 times per day
 Lifting objects weighing more than 10
pounds if done more than twice per minute
more than 2 hours total per day
 Gripping an unsupported object(s)
weighing 10 or more pounds per hand, or
gripping with a force of 10 or more
pounds per hand, more than 2 hours total
per day (comparable to clamping light
 Squatting more than 2 hours total per
day
 Kneeling more than 2 hours total per
day
 Lifting objects weighing more than 25
pounds above the shoulders, below the
knees or at arms length more than 25
times per day
Moderate to High Hand-Arm Vibration
 Using impact wrenches, carpet strippers,
chain saws, percussive tools (jack
hammers, scalers,riveting or chipping
hammers) or other hand tools that typically
have high vibration levels more than 30
minutes total per day
 Using grinders, sanders, jig saws or other
hand tools that typically have moderate
vibration levels more than 2 hours total per
day
 What can contribute to an injury?
 Psychosocial i. e. stress
 Activities & Hobbies i. e. house work
 Organization i. e. shift length
 Environment i. e. heat
 Physical i. e. heavy lifting
 Individual Characteristics i. e. fitness
level
 Biomechanical risk factors at work
place
 Configuration and arrangement of the
environment
 Forces exerted
 Postures adopted
 Frequency and variation in time of forces
and postures
Elements of work relatedness
 Diagnosis
 Association of the disorder with work
 Causation of disorders
 Cause effect relationship

 Temporal relationship and change of work

 Tendon related disorders
 Exposure response relationship between
wrist /hand tendinitis and the forcefulness
and frequency of the effort
 In the hand and in the shoulder these
disorders have shown a moderate to
strong and consistent relationship to
various risk factors at work
 Cross sectional studies
 Confounders like age ,smoking were not
considered
 Shoulder tendinitis
 Cross sectional studies
 Welders and plate workers had high
prevalence
 Odds ratio of 11 was seen
 Epicondylitis
 Cross sectional study and a cohort
 Cohort study-31 month follow up
 De quervains s tendinitis
 Exposure response was studied
 High repetition odds ratio 3.3
 High force 6.1
 High force high repetition 29
 Conclusion
 Tendinitis at the shoulder and wrist/hand
tendinitis associated with exposure to work
 Nerve related disorders
 Carpal tunnel syndrome is one of the most
studied WMSD
 A strong association has been found
between low force repetitive work, forceful
exertions, awkward postures
 Females more affected than males
 The relative risk was 4 to 15 for high force
high repetition
 Low repetition 2 to 5
 Flexed postures
 Radiculopathy
 No exposure response relationship
 Power of the studies were low
 Conclusion
 Carpal tunnel syndrome
 TOS
 Unspecified or unknown disorders
 There has been a positive relationship
between work environment and vague
pain in the neck and the upper extremity
 The odds ratio was 2 to 7
 Osteoarthrosis
 Risk ratios 2-4
 Consistency of this association does not
exist
Pathophysiology of WMSD
 Fatigue
 When muscular work is performed over a
prolonged period fatigue develops
 Without adequate recovery can lead to
WMSD
 Causal mechanisms
 Recruitment of motor unit
In monotonous work is performed this
stereotyped movement pattern will lead to
fatigue
Changes in individual muscle cells
Reflex propagation
 Mechanical forces:-
The recruitment pattern
The magnitude of the force
The architecture of the muscle
 High load –acute injuries
 Low load microruptures
 Eccentric work
 Frictional force
 Intramuscular pressure
 400 to 500 mm Hg
 Muscle volume increases at high loads
 Compartment syndrome
 Fiber atrophy ,fiber splitting, edema, and
decreased muscle oxygen tension
 Blood flow
 Free oxygen radicals are formed which
causes cell damage
 During static contractions blood flow
through the small blood vessels
diminishes
 Metabolic factors
 Accumulation of lactic acid
 Reduction in glycogen stores
 Work
exposure
requirements

Muscle activity Mechanical damage

Physiological
response Muscle fatigue Cramp

recovery Inadequate recovery

Long Sustained or
Term Degenerative
improved physical
effect changes Pain
capacity
 Motor behavior and altered patterns of
movements appear
 Tendon injury is dependent on the force,
frequency,and duration of the repetitive
exposure
 Inflammatory changes are more seen than
degenerative
 Inflammatory response if followed by
fibrotic response
 Ultimately leads to failure
 Macrophage infiltration of the muscles
 Cytokines are present
 Both local systemic inflammatory
responses are seen
 Periosteal or marrow edema ,periosteal
bone sites of ligaments and tendons show
evidence of pathologically woven
immature bone
 Nerve injury
 Cyclic loading has effects on grip
strength ,compound muscle action
potentials ,amplitude and integrity of the
blood brain barrier
 Effect of force not known
 Compression may cause mechanical
disruption of nerve structures as well as
compromise vascular supply
 Endoneurial fluid ,axoplasm and myelin
move away from the area of compression
 Pressure on the nerve causes anoxia by
reducing its blood flow
 Disruption of the blood brain barrier
 Axonal demyelination and degeneration
 Neural fibrosis
Evidence of CNS reorganization
 Examinations of somatosensory evoked
potentials in patients with chronic CTS
shows increased amplitude in the spinal
cord ,brainstem and sensoricortical
regions
 Degradation of the somatosensory cortex
in repetitive work
 A loss of spatial discrimination in the form
of gap detection and single touch
localization has been observed
 SENSATION
CNS MOTOR
ABILITIES

ACUTE
PAIN
INFLAMMATION
TISSUE OR
INJURY FIBROSIS DISCOMFORT
CHRONIC OR LOSS
SYSTEMIC OF FUNCTION
INFLAMMATION

BIOMECHANICAL
TISSUE
PATHOLIGICAL TOLERANCE
REORGANI
REMODELING