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Journal of Occupational Rehabilitation

, Volume 11, Issue 1, pp 1–21 | Cite as

Understanding Work-Related Upper Extremity Disorders: Clinical Findings in 485 Computer Users, Musicians, and Others

  • Emil F. Pascarelli
  • Yu-Pin Hsu
Article

Abstract

Four hundred eighty five patients whose chief complaints were work related pain and other symptoms received a comprehensive upper-body clinical evaluation to determine the extent of their illness. The group had a mean age of 38.5 years. Sixty-three percent of patients were females. Seventy percent were computer users, 28% were musicians, and 2% were others engaged in repetitive work. The time between the onset of symptoms and our initial visit ranged from 2 weeks to over 17 years. A majority sought care within 30 months with the greatest number of them seeking care before 12 months. Fifty nine percent of subjects were still working when seen despite increasing pain and symptoms such as weakness, numbness, tingling, and stiffness. Following a history, a physical assessment utilizing commonly employed clinical tests were performed including evaluation of joint range of motion, hyperlaxity, muscle tenderness, pain, strength, and imbalance. Neurologic tests included Tinel's sign performed in wrist, elbow, tricipital sulcus, and neck and tests for thoracic out syndrome (TOS). Specific tests such as Finkelstein's test for deQuervain's tenosynovitis, Phalen's test for carpal tunnel syndrome and grip strengths were included in the examination protocol. Significant findings included postural misalignment with protracted shoulders (78%), head forward position (71%), neurogenic TOS (70%), cervical radiculopathy (0.03%), evidence of sympathetic dysfunction (20%), and complex regional pain syndrome (RSD) (0.6%). Hyperlaxity of fingers and elbows was found in over 50%, carpal tunnel syndrome in 8%, radial tunnel syndrome in 7%, cubital tunnel in 64%, shoulder impingement in 13%, medial epicondylitis in 60%, lateral epicondylitis in 33%, and peripheral muscle weakness in 70%. We conclude that despite initial presentation distally, work-related upper-extremity disorders are a diffuse neuromuscular illness with significant proximal upper-body findings that affect distal function. While neurogenic TOS remains a controversial diagnosis, the substantial number of patients with positive clinical findings in this study lends weight to the concept that posture related neurogenic TOS is a key factor in the cascading series of physical events that characterize this illness. A comprehensive upper-body examination produces findings that cannot be obtained through laboratory tests and surveys alone and lays the ground work for generating hypotheses about the etiology of work related upper-extremity disorders that can be tested in controlled investigations.

work-related upper-extremity disorders computer users medical examination 

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REFERENCES

  1. 1.
    Department of Labor. Occupational safety and health administration, 29CFRpart 1910 Ergonomics program, proposed rule, Part 22. November 23, 1999.Google Scholar
  2. 2.
    Fishbein M, Middlestadt SE, Oltati V. Medical problems among ICSOM musicians: Overview of a national survey. Med Probl Perform Art 1988; 3: 1-8.Google Scholar
  3. 3.
    Guay AH. Commentary: Ergonomically related disorders in dental practice. J Am Dent Ass 1998; 129(2): 184-186.Google Scholar
  4. 4.
    Marklin RW, Monroe JF. Quantiative biomechanical analysis of wrist motion in bone-trimming jobs in the meat packing industry. Ergonomics 1998; 41(2): 227-237.Google Scholar
  5. 5.
    Silverstein BA, Stetson DS, Keyserling WM, Fine LJ.Work-related musculoskeletal disorders: Comparison of data sources for surveillance. Am J Industrial Med 1997; 31(5): 600-608.Google Scholar
  6. 6.
    Mackinnon SE, Novak CB. Clinical perspective: Repetitive strain in the workplace. J Hand Surg 1997; 22A(1): 2-18.Google Scholar
  7. 7.
    Sheon RP. Repetitive strain injury. 1. An overview of the problem and the patients. The Golf Group. Postgraduate Med 1997; 102(4): 53-56, 62-68.Google Scholar
  8. 8.
    Pascarelli EF, Quilter D. Repetitive strain injury: A computer user's guide. New York: John Wiley & Sons, 1994.Google Scholar
  9. 9.
    Mackinnon SE, Novak CB. Clinical commentary: Pathogenesis of cumulative trauma disorder. J Hand Surg 1994; 19A(5): 873-883.Google Scholar
  10. 10.
    Stone WE. Occupational overuse syndrome in other countries. J Occup Health Safety Aust NZ 1986; 3(4): 400.Google Scholar
  11. 11.
    Maeda K. Occupational cervicobrachial disorder and its causative factors. J Human Ergol 1977; 6: 193-202.Google Scholar
  12. 12.
    Maeda K, Horiguchi S, Hosokawa M. History of the studies on occupational cervico-brachial disorders in Japan and remaining problems. J Human Ergol 1982; 11: 17-29.Google Scholar
  13. 13.
    Lederman RJ, Calabrese LH. Overuse syndromes in instrumentalists. Med Probl Perform Art 1986; 1: 7.Google Scholar
  14. 14.
    Armstrong TJ. An ergonomics guide to carpal tunnel syndrome. In: Armstrong TJ, ed. Ergonomics guides. Fairfax, VA: American Industrial Hygiene Association, 1983.Google Scholar
  15. 15.
    Armstrong TJ, Buckle P, Fine LJ, HagbergM, Jonsson B, Kilbom A, Kuorinka IA, Silverstein BO, Sjogaaro G, Viikari-Juntura ER.Aconceptual model forwork-related neck and upper-limb musculoskeletal disorders. Scand J Work, Environ Health 1993; 19: 73-84.Google Scholar
  16. 16.
    Rosenman KD, Gardiner JC, Wang J, Biddle J, Hogan A, Reilly MJ, Robert K, Welch E. Why most workers with occupational repetitive trauma do not file for workers' compensation. J Occup Environ Med 2000; 42(1): 25-34.Google Scholar
  17. 17.
    Zuger A. Are doctors losing touch with hands-on medicine? The New York Times (Science Time), July 13, 1999, pp. 1, 9.Google Scholar
  18. 18.
    Silversides A. Confusion surrounding repetitive strain injury highlighted at conference.CMAJ1997; 156(10): 1459-1460.Google Scholar
  19. 19.
    Like Athletes, Workers Need Conditioning for Computer Jobs. The New York Times November 11, 1999.Google Scholar
  20. 20.
    Examine Above the Elbow. The New York Times November 25, 1999.Google Scholar
  21. 21.
    Hadler NM. Coping with arm pain in the workplace. Clin Orthoped Relat Res 1998; (351): 57-62.Google Scholar
  22. 22.
    Beals RK. The normal carrying angle of the elbow. Clin Orthoped 1976; 119: 194.Google Scholar
  23. 23.
    Pascarelli EF. Evaluation and treatment of repetitive motion disorders. In Machleder HI, ed. Vascular disorders of the upper extremity, 3rd edn. Mt. Kisco, NY: Futura, 1998, pp. 171-196.Google Scholar
  24. 24.
    Linburg RM, Comstock BE. Anomalous tendon slips from the flexor pollicis longus to the flexor digitorum profunds. J Hand Surg 1979; 4A: 79-83.Google Scholar
  25. 25.
    Lister G. The hand: Diagnosis and indications, 2nd edn. New York: Churchill Livingstone, 1984, pp. 351-386.Google Scholar
  26. 26.
    Lapidus PW, Fenton R. Stenosing tenovaginitis at the wrist and fingers: Report of 423 cases in 369 patients with 354 operations. Arch Surg 1952; 64: 475-487.Google Scholar
  27. 27.
    Finkelstein H. Stenosing tenovaginitis at the radial styloid process. J Bone Joint Surg 1930; 12: 509.Google Scholar
  28. 28.
    American Society for Surgery of the Hand. The Hand, Examination and Diagnosis, 2nd edn. New York: Churchill Livingstone, 1983.Google Scholar
  29. 29.
    Phalen GS. Spontaneous compression of the median nerve at the wrist. J AmMed Ass 1951; 145: 1128-1133.Google Scholar
  30. 30.
    Phalen GS. The Carpal tunnel syndrome. J Bone Joint Surg 1966; 48A: 211-228.Google Scholar
  31. 31.
    Phalen GS. The carpal tunnel syndrome: 17 years experience in diagnosis and treatment of 654 hands. J Bone Joint Surg 1968; 48A: 211-228.Google Scholar
  32. 32.
    Magee DJ. Orthopedic physical assessment. Philadelphia, PA: W.B. Saunders Company, 1987, pp. 76-77.Google Scholar
  33. 33.
    Bear-Lehman J, Abreu BC. Evaluating the hand: Issues in reliability and validity. Phys Ther 1989; 69: 1025-1033.Google Scholar
  34. 34.
    Lister G. The hand: Diagnosis and indications, 2nd edn. New York: Churchill Livingstone, 1984, p. 152.Google Scholar
  35. 35.
    Moldover V. Tinel's sign-Its characteristics and significance. J Bone Joint Surg 1978; 60A: 412Google Scholar
  36. 36.
    Spurling RG, Scoville WR. Lateral rupture of the cervical intervertebral disc. Surg Gynecol Obstet 1944; 78: 350-357Google Scholar
  37. 37.
    Schwartzman RJ. Brachial plexus traction injuries. Frontiers Hand Rehab 1991; 7: 547-556.Google Scholar
  38. 38.
    Mackinnon SE, Novak CB. Evaluation of the patient with thoracic outlet syndrome. Semin Thorac Cardiovasc Surg 1996; 8(2): 190-200.Google Scholar
  39. 39.
    Roos DB. Thoracic outlet nerve compression. In: Rutherford RB, ed. Vascular surgery. Philadelphia, PA: Saunders, 1989, pp. 858-875.Google Scholar
  40. 40.
    Machleder HI, Introduction to Neurovascular compression syndromes at the thoracic outlet. In Machleder HI, ed. Vascular disorders of the upper extremity, 3rd edn. Mt. Kisco, NY: Futura Publishing Company, Inc., 1998, pp. 109-135.Google Scholar
  41. 41.
    Roos DB. Newconcepts of thoracic outlet syndrome that explain etiology, symptoms diagnosis and treatment. Vasc Surg 1979; 13: 313-321.Google Scholar
  42. 42.
    Roos DB. Overview of thoracic outlet syndromes in vascular disorders of the upper extremity. In: Machleder HI, ed. Vascular disorders of the upper extremity, 2nd edn. Mt. Kisco, NY: Futura Publishing Company, 1989, pp. 155-177.Google Scholar
  43. 43.
    Bear-Lehman J. Upper extremity cumulative trauma disorder and return to work assessment. Work 1997; 8: 3-14.Google Scholar
  44. 44.
    Gillenson SP, Parets N, Bear-Lehman J, Stanton PB. The effect of wrist position on testing light touch sensation using the Semmes-Weinstein pressure aesthesiomether: A preliminary study. J Hand Ther 1998; 11(1): 27-31.Google Scholar
  45. 45.
    Kendall EP, McCreary BK. Muscles: Testing and function. Baltimore: Williams & Wilkins, 1983.Google Scholar
  46. 46.
    Larsen RD, Takagishi N, Posch JL. The pathogenesis of Dupuytren's contracture. J Bone Joint Surg 1960; 42A: 993-1007.Google Scholar
  47. 47.
    Mikkelsen OA. Dupuytren's disease-A study of the pattern of distribution and stage of contracture in the hand. The Hand 1976; 8: 265-271.Google Scholar
  48. 48.
    Andren L, Eiken O. Arthrographic studies of wrist ganglions. J Bone Joint Surg 1971; 53A: 299-302.Google Scholar
  49. 49.
    Pascarelli E, Kella J. Soft-tissue injuries related to use of the computer keyboard: A clinical study of 53 severely injured persons. J Occup Med 1993; 35: 5.Google Scholar
  50. 50.
    Garden RS. Tennis elbow. J Bone Joint Surg 1961; 43B: 100-106.Google Scholar
  51. 51.
    Coonrad RW, Hooper WR. Tennis elbow: Its source, natural history, conservative and surgical management. J Bone Joint Surg. 1973; 55A: 1177-1182.Google Scholar
  52. 52.
    Begg RE. Epicondylitis or tennis elbow. Orthopaed Rev 1980; 9: 33-42.Google Scholar
  53. 53.
    Leach RE, Miller JK. Lateral and medial epicondyitis of the elbow. Clin Sports Med 1987; 6: 259-272.Google Scholar
  54. 54.
    Lister GD, Belsole RB, Kleinert HE. The radial tunnel syndrome. J Hand Surg 1979; 4: 52-60.Google Scholar
  55. 55.
    Regan WD, Morrey BF. Entrapment neuropathies about the elbow. In DeLee JC, Drez D Jr, eds.Orthopaedic sports medicine: Principles and practice, vol. 1. Philadelphia, PA: WB Saunders, 1994, pp. 844-859.Google Scholar
  56. 56.
    Apfelberg DB, Larson SJ. Dynamic anatomy of the ulnar nerve at the elbow. Plast Reconstr Surg 1973; 51: 79-81.Google Scholar
  57. 57.
    Macnicol MF. Extraneural pressures affecting the ulnar nerve at the elbow. Hand 1982; 14: 5-11.Google Scholar
  58. 58.
    Gray H. In Goss CM, ed. Anatomy of the human body, 26th edn. Muscles and fascial of the upper extremity. Philadelphia: Lea & Febiger, 1954, p. 500.Google Scholar
  59. 59.
    Liebovic SJ. Martin-Gruber revisited. J Hand Surg. 1992; 17: 47.Google Scholar
  60. 60.
    Sucher BM, Health DM. Thoracic outlet syndrome-A myofascial variant: Part 3. Structural and postural considerations. JAOA 1993; 93: 334-345.Google Scholar
  61. 61.
    Mannheimer JS, Rosenthal RM. Acute and chronic postural abnormalities as related to craniofacial pain and temporomandibular disorders. Dent Clin North Am 1991; 35: 185-208.Google Scholar
  62. 62.
    ZohnDA. Musculoskeletal pain: Diagnosis and physical treatment, 2nd edn. Boston: Little Brown Company, 1988, pp. 183-188.Google Scholar
  63. 63.
    Kamkar A, Irrgang JJ, Whitney, SL. Nonoperative management of secondary shoulder impingement syndrome. JOSPT 1993; 17: 212-223.Google Scholar
  64. 64.
    Hawkins RJ, Abrams JS. Impingement syndrome in the absence of rotator cuff tear (Stages 1 and 2). Orthop Clin North Am 1987; 18(3): 373-382.Google Scholar
  65. 65.
    James JJP. The etiology of scoliosis. J Bone Joint Surg 1970; 52B: 410.Google Scholar
  66. 66.
    White AA. Kinematics of the normal spine as related to scoliosis. J Biomech 1971; 4(5): 405-411.Google Scholar
  67. 67.
    Kondo K, Molgaard CA, Kurland LT, Onofrio BM. Protruded intervertebral cervical disk: Incidence and affected cervical level in Rochester, Minnesota, 1950 through 1974. Minn Med. 1981; 64: 751-753.Google Scholar
  68. 68.
    Kelsey JL, Githens PB, Walter SD, Southwick WO, Weil U, Holford JR, Ostfeld AM, Calogero AM, O'Connor T, White AA 3rd. An epidemiological study of acute prolapsed cervical intervertebral disc. J Bone Joint Surg 1984; 66A: 907-914.Google Scholar
  69. 69.
    Wilshire WH. Super numerary first rib: Clinical records. Lancet 1860; 2: 633.Google Scholar
  70. 70.
    Juvonen T, Satta J, Laitala P, Luukkonen K, Nissinen J. Anomalies at the thoracic outlet are frequent in the general population. Am J Surg 1995; 170: 33-37.Google Scholar
  71. 71.
    Roos DB. Pathophysiology of congenital anomalies in thoracic outlet syndrome. Acta Chir Belgica 1980; 79: 353-361.Google Scholar
  72. 72.
    Machleder HI. Neurogenic thoracic outlet compression syndrome. In Machleder HI, ed. Vascular disorders of the upper extremity, 3rd edn. Mt. Kisco, NY: Futura Publishing Company, Inc., 1998, pp. 131-135.Google Scholar
  73. 73.
    Liu JE, Tahmoush AJ, Roos DB, Schwartzman, RJ. Shoulder-arm pain from cervical bands and scalene muscle anomalies. J Neurolog Sci 1995; 128: 175-180.Google Scholar
  74. 74.
    Coote H. Exostosis of the left transverse process of the seventh cervical vertebrae, surrounded by blood vessels and nerves, successful removal. Lancet 1861; 1: 360-361.Google Scholar
  75. 75.
    Gilliat RW, LeQuesne PM, Logue V, Sumner AJ.Wasting of the hand associated with a cervical rib or band. J Neurol Neurosurg Psychiatr 1970; 33: 615-624.Google Scholar
  76. 76.
    Roos DB. Congenital anomalies associated with thoracic outlet syndrome: Anatomy, symptoms, diagnosis and treatment. Am J Surg 1976; 132: 771-778.Google Scholar
  77. 77.
    Graffman G. Doctor, can you lend an ear? Med Probl Perform Art 1986; 1: 1-3.Google Scholar
  78. 78.
    Hochberg FH, Harris SU, Blattert TR. Occupational hand cramps: Professional disorders of motor control. Hand Clin 1990; 6(3): 417.Google Scholar
  79. 79.
    Hochberg FH, Lefert RD, Heller MD, Merriman L. Hand difficulties among musicians. JAMA 1983; 249: 1896.Google Scholar
  80. 80.
    Lederman RJ. Occupational cramp in instrumental musicians. Med Probl Perform Art 1988; 3: 2-45.Google Scholar
  81. 81.
    Merriman, L, Newmakr, J, Hochberg FH. A focal movement disorder of the hand in six pianists. Med Probl Perform Art 1986; 1: 1: 17.Google Scholar
  82. 82.
    Newmark J, Hochberg FH. Isolated painless manual incoordination in 57 musicians, J Neuro Neurosurg Psychiatr 1987; 50: 291.Google Scholar
  83. 83.
    Lederman RJ. Thoracic outlet syndrome: Review of the controversies and a report of 17 instrumental musicians, Med Probl Perform Art 1986; 2: 87.Google Scholar
  84. 84.
    Foletti G, Regli F. Characteristics of chronic headaches after whiplash injury. Presse Medicale 1995; 8 (24): 1121-3.Google Scholar
  85. 85.
    Ford CV. Somatization and fashionable diagnoses; illness as a way of life. Scand J Work, Environ Health 1997; 23(3): 7-16.Google Scholar
  86. 86.
    Hadler NM. Repetitive upper-extremity motions in the workplace are not hazardous. J Hand Surg Am 1997; 22(1): 19-29.Google Scholar
  87. 87.
    de Oliveira JT. RSI-repetitive strain injury. A questionable and harmful concept. Arquivos de Neuro-Psiquiatria 1999; 57(1): 126-131.Google Scholar
  88. 88.
    Bell DS. "Repetitive Strain Injury" an iatrogenic epidemic of simulated injury. Med J Aust 1989; 131: 280-288.Google Scholar
  89. 89.
    Brooks P. Regional Pain Syndrome-The disease of the '80s. Bull Post-Grad Committee Med.U of Sydney 1986; 42: 55-59.Google Scholar
  90. 90.
    Ferguson D. The "new" industrial epidemic. Med J Aust 1984; 140: 318-319.Google Scholar
  91. 91.
    Ireland DC. Psychological and physical aspects of occupational arm pain. Br J Hand Surg 1988; 13B: 5-10.Google Scholar
  92. 92.
    Lucire Y. Neurosis in the workplace. Med J Aust 1986; 145: 323-326.Google Scholar
  93. 93.
    Mclntosh P. Technology spawns its own disease. The Age November 21, 1984, p. 17.Google Scholar
  94. 94.
    Weigert BJ, Rodriguez AA, Radwin RG, Sherman J. Neuromuscular and psychological characteristics in subjects with work-related forearm pain. Am J Phys Med Rehab 1999; 78(6): 545-551.Google Scholar
  95. 95.
    Nathan PA, Keniston RC, Meadows KD. Lockwood RS. Validation of occupational hand use categories. J Occup Environ Med 1993; 35: 1034-1042.Google Scholar
  96. 96.
    Tenner E. Why Things Bite Back: Technology and the Revenge of Unintended Consequences. New York. A Knopf, 1996.Google Scholar
  97. 97.
    Reid J, Ewan C, Lowy E. Pilgrimage of pain: The illness experiences of women with repetition strain injury and the search for credibility. Soc Sci Med 1991; 32: 601-612.Google Scholar
  98. 98.
    Ireland DCR. Repetition strain injury: The Australian experience-1992 update. J Hand Surg. 1995; 20A: S53-S56.Google Scholar
  99. 99.
    Jordan SE, Ahn SS, Freischlag, JA, Gelabert HA, Machleder H. Selective Botulinum Chemodenervation of the Scalene Muscles for Treatment of Neurogenic Thoracic Outlet Syndrome. Ann Vasc Surg 2000; 14: 365-369.Google Scholar
  100. 100.
    Goldenberg DL. Controversies in fibromyalgia and myofascial pain syndrome. In Arnoff GM, ed. Evaluation and treatment of chronic pain, 2nd edn. Baltimore, MD: Williams & Wilkins, 1992, pp. 165-175.Google Scholar
  101. 101.
    Simons DG. Myofascial pain syndromes: Where are we? Where are we going? Arch Phys Med Rehabil 1988; 69: 207-212.Google Scholar
  102. 102.
    Sucher BM. Thoracic outlet syndrome-A myofascial variant: Part 2. Treatment. JAOA 1990; 90: 810-823.Google Scholar
  103. 103.
    Fridén J, Sjö,ström M, Erblom B. Myofibrillar damage following intense eccentric exercise in man. Int J Sports Med 1983; 4: 45-51.Google Scholar
  104. 104.
    Dennett X, Fry HJ. Overuse syndrome: A muscle biopsy study. Lancet 1988; 1: 8591: 905-908.Google Scholar
  105. 105.
    Machleder Hl, Moll F, Verity A. The anterior scalene muscle in thoracic outlet compression syndrome: Histochemical and morphometric studies. Arch Surg 1986; 121: 1141-1144.Google Scholar
  106. 106.
    Mauro A. Satellite cell of skeletal muscle fibers. J Biophys Biochem Cytol 1961; 9: 493-495.Google Scholar
  107. 107.
    Campion DR. The muscle satellite cell: A review. Int Rev Cytol 1984; 87: 225-251.Google Scholar
  108. 108.
    Carlson BM. The satellite cell and skeletal muscle regeneration: The degneration and regeneration cycle in repetitive motion disorders of the upper extremity. In American Academy of Orthopedic Surgeons Symposium, Rosemont, IL, 1995, pp. 313-322.Google Scholar
  109. 109.
    Lundborg G. Structure and function of the intraneural microvessels as related to trauma, edema formation and nerve function. J Bone Joint Surg 1975; 57A: 938-948.Google Scholar
  110. 110.
    Lundborg G, Myers R, Powell H. Nerve compression injury and increased endoneurial fluid pressure: "Miniature compartment syndrome." Neurol Neurosurg Psychiatr 1983; 46: 1119-1124.Google Scholar
  111. 111.
    Seddon JH. Three types of nerve injury. Brain 1943; 66: 237-288.Google Scholar
  112. 112.
    Dahlin LB, Shyu BC, Danielsen N, Anderssen SA. Effects of nerve compression or ischaemia on conduction properties of myelinated and non-myelinated nerve fibers: An experimental study in the rabbit common peroneal nerve. Acta Physiol Scand 1989; 136: 97-105.Google Scholar
  113. 113.
    Veldman PH, Reynen HM, Arntz IE, Goris RJ. Signs and symptoms of reflex sympathetic dystrophy: Prospective study of 829 patients. Lancet 1993; 342: 1012-1016.Google Scholar
  114. 114.
    Benjamin M, Ralphs J. Functional and developmental anatomy of tendons and ligaments. In: Gordon SL, Blair SJ, Fine LJ, eds. Repetitive motion disorders of the upper extremity. Rosemont, IL: American Academy of Orthopedic Surgeons, 1995, pp. 185-203.Google Scholar
  115. 115.
    Novak CB. Conservative management of thoracic outlet syndrorne. Semin Thorac Cardiovasc Surg 1996; 8(2): 201-207.Google Scholar

Copyright information

© Plenum Publishing Corporation 2001

Authors and Affiliations

  1. 1.Department of Medicine, College of Physicians and SurgeonsColumbia UniversityNew York
  2. 2.Department of Occupational Therapy, College of Physicians and SurgeonsColumbia UniversityNew York

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