Physical Therapy Approach to Cumulative Trauma
Disorders (CTD’s): Including
Ergonomics specific to HealthConnect.
Laurie Kenny PT,OCS
Physical Therapist, Orthopedic Clinical Specialist
The symptoms and dysfunction associated with CTD’s are
primarily the consequences of poor posture. So what do I tell
patients?“The good news is I can help you…You have pain from…”
A Posture Problem!
• Hand intensive tasks(such
as typing) frequently lead to
forward head postures.
• Prior neck injuries (MVA)
can weaken the neck
stabilizing muscles, making
it hard to correct posture.
• Repetitive use of the hand
in poor posture irritates the
nerves, resulting in arm
symptoms.
Case # 1 Forearm Strain
27 yo R handed caterer, 3 wk s/p lifting bulk food boxes and sacks,
felt a “pop” in R forearm w immediate weakness and pain. Is
avoiding using R hand. PHx:(-). GH: diabetic
Referred to physical therapy for diagnosis of “forearm muscle
strain”.
Case # 1 Body Chart
Do you see a specific pain pattern?
Goals for today: Help you…
ƒBecome comfortable using a
movement test of nerve
sensitivity, called the upper
limb tension test.
ƒUse patient education
resources to start patients on
simple exercises.
ƒRecognize postural problems
associated with CTD’s.
Does the research help us decide what treatments are
effective for CTD,RSI, non-specific upper extremity pain ?
NOT YET!
Quality of intervention studies=“Poor”
Limited evidence for alternative keyboards,
exercise as compared to massage, taking breaks
during computer work, massage+manual therapy,
manual therapy+exercise.
Verhagen et al, Cochrane Database Syst Rev, 2006.
Back to Basics
Value of good history, and complete exam.
Once you have determined the patient does not have
a local or (single body part) problem…
Then can discuss treatment plan in terms of treating
a posture-related problem.
The key is having a tool to communicate progress to
the patient.
Arm Self-Test
Rate your arm on this scale of 0-5, by moving your arm into each position you can
without feeling symptoms of tightness, tingling, or pain. Your rating is the position
where you start to feel any symptoms in your arm. If you are unable to let your arm
rest comfortably straight by your side, your rating is 0 (zero).
***Do your self-test before and after you exercise.
The Upper Limb Tension Test (ULTT)
The “straight leg raise” test of the arm:
Positive Test
Reproduces symptoms and/or
restricted range
Change in symptoms or range
with sensitizing movements
Precaution/Contraindications
Neuro signs, cord signs,
severe symptoms
*The Arm Self-Test is an active
version of the ULTT*
Posture Correct
Stabilize-Think!
Activates the deep neck
flexor muscles that
stabilize the neck.
*Sit or stand upright.
*Place fist under jaw.
*Gently tuck chin into
fist while actively lifting
top of head, (think tall).
Case # 1:Posture @ Initial Exam
Case #1:Posture after first treatment of roller
ex & towel traction.
Exercise Progression
Discharge, 6th visit
Case 2: Recurrent problem despite prior Tx.
S: 53 Y female, Right handed Assistant
Information analyst x1yr (23yrs overall as
executive assistant), on modified work. Current
job duties: sets up computer equipment, needs
to get under desks, lift up to 50#, but she is
hoping to no longer have to do lifting. She works
9hr days and her work practice is that she
forgets to take breaks. DOI: 4/1/08, gradual
worsening neck,R UE symptoms. She had prior
PT treatment at Kaiser, and at community PT
clinic. She describes treatment as primarily
massage, she admits to not remembering her
exercises.
Current symptoms: R neck midline pain 3-4/10,
that radiates to Right UE to hand and Left to
upper arm, she also has intermittent R medial
forearm pain 2/10, tightness and tingling finger
1-4.
Hand Exercises: Tendon Glides
“Exercise Moment” for Seated Workers
Self-care tip sheet, TPMG Regional Health Education
Key points from case examples
1. Importance of history (why now?), body chart
(local vs. non-specific).
2. The role of self-assessment tools in patient
management.
3. The concept of minor nerve injury in patients
with non-specific arm pain.
4. Cervical posture dysfunction must be
evaluated and managed.
Ergonomics:
education, education, education….
Self-care tips for clinicians using HealthConnect: Applying the same principles and
treatment advice used on patients with CTD problems, to treat ourselves.
Ergonomic Risk Factors
Awkward postures
Sustained postures
Vibration
Contact stress
Force Absorption
Repetition!
The challenges of using a computer mouse
Difficult to place wrist,
hand, shoulder in neutral
relaxed position.
Increased workload for the
dominant hand (if you use
your dominant hand for
the mouse).
Pen test: Helps you place your hand in better
posture on the keyboard
Correct
Incorrect
Place a pen on top of your hand with one end between
fingers 2-3, the other end of the pen pointed toward your
wrist .
Posture and Communication:
Teaching by Example
Place the patient just to the side of
the monitor to minimize turning
of your neck.
The patient is then closer to you
making it easier to involve them
in the visit.
Patient Ed resources included in your handout
Mousing Solutions
Switching the Mouse to the Left Side
Q: Why should I switch the mouse to my left side?
A: There are two important reasons to switch your mouse to your l eft side: to reduce
excessive outward rotation strain on your right shoulder, and t o reduce the cumulative
wear and tear on your r ight hand.
More resources.
Lotus notes shortcuts on a separate handout.
Keyboarding Solutions
Learning to Type without Looking at the Keys
Q: Why should I take the extra time to learn to type without looking at the keys?
A: You can reduce the risks of injury to you r neck and upper extremities that occur from
awkward posture, static muscle holding and overuse of fingers associated with huntand-peck typing.
Interactive Pt Ed: Healthy Living video on KP physician web page..
Questions? Laura.Kenny@KP.org
Thank You!