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Cumulative trauma disorders have increased five-fold since 1979 and now account for up to 47% of workplace injuries. Nerve entrapment, tendonitis, and other soft tissue injuries are the most common diagnostic groups. Both occupational and non-occupational factors contribute to the etiology of these disorders. Epidemiology, differential diagnosis, and interventions for treatment are reviewed.
Cumulative trauma disorders have been medically described for about 100 yr and have been related to physical activities for nearly 300 yr. Yet, avoiding these disorders in the shop and office is becoming of urgent concern only now, particularly because of the Occupational Safety and Health Administration's (OSHA's) investigation and enforcement program. Such disorders occur most often in soft tissues of the body, particularly at tendons and their sheaths. They may irritate or damage nerves and impede blood flow. They are frequent in the hand/wrist/forearm area; for example, in the carpal tunnel and in the shoulder and neck. Although controversy exists, occupational and leisure activities are generally believed to cause or aggravate cumulative trauma disorders. The major activity-related factors are rapid repetitive movements, forceful movements, static muscle loading, inappropriate body postures, vibrations, and cold. Yet, the quantitative thresholds above which cumulative trauma disorders are expected to occur are largely unknown and need to be researched. Furthermore, certain health conditions may make individuals predisposed to cumulative disorders. For most cumulative trauma disorders, physical activities and job procedures can be identified that are related to the occurrence of cumulative trauma disorders. This allows the establishment of generic and specific recommendations for the avoidance of conditions that may lead to cumulative trauma disorders in the workshop or the office.
Cumulative trauma disorders due to performance of repetitive tasks account for more than 50% of all occupational illnesses in the United States today. Employees affected by these disorders frequently experience substantial pain and functional impairment that may require a change in occupation. For the employer, these injuries result in loss of productivity and increased costs in the form of higher medical expenses and disability payments for injured workers. Successful treatment of work-related repetitive tissue injuries depends on early diagnosis and appropriate therapy. Prevention requires identifying sites and tasks that place employees at risk of injury and supporting efforts to develop safer work environments.
Upper extremity cumulative trauma disorders became a potentially significant occupational hazard among sign language interpreters at the National Technical Institute for the Deaf in the 1988-89 academic year. The following case control study was conducted to identify factors that might play a role in developing, exacerbating, and maintaining upper extremity cumulative trauma disorders among interpreters. Investigations were conducted to determine whether medical status, physical capacities, interpreting styles, pain, fatigue, and job stress differed among NTID's sign language interpreters. This report provides a general summary of selected findings as well as a conceptual framework that should help clarify the factors associated with upper extremity cumulative trauma disorders in sign language interpreters. The results indicated that the upper extremity cumulative trauma disorder diagnosed most often is tendinitis rather than a nerve entrapment syndrome (e.g., carpal tunnel syndrome). Analysis of the frequency of potential biomechanical risk factors indicated that those reporting pain demonstrated higher frequency of hand and wrist deviations from the neutral position, higher frequency of the upper extremities leaving a predefined work space, fewer rest breaks during interpreting sessions, and higher evaluator ratings of pace of finger and hand movements. Specific features of interpreting styles were associated with increased pain and fatigue.
The current status of cumulative trauma disorder of the upper limb is examined from the standpoint of its long history, its current controversies, and the philosophic basis of the present laws, which control management of the condition. The future needs that should permit cumulative trauma disorders to be better understood, better managed, and better legislated are also addressed.
The incidence of cumulative trauma disorder (CTD) has become noteworthy in plants that rely on automated production. This rise was evident in an Ohio poultry company. The purpose of this study was to develop a screening tool to detect employees who might be at risk of sustaining a CTD injury and to identify trends of CTD at specific workstations. Thirty-five employees at three workstations completed a questionnaire and underwent a physical examination. Results identified 24 employees with a potential for CTD, and these employees were recommended for remediation. Job modifications and supportive devices were placed in the workplace. A newly designed industrial wrist splint was developed for this study. The personnel department has noted that employee complaints of upper extremity discomfort have decreased.
1. Elements critical to a successful medical management program include cumulative trauma disorder (CTD) surveillance, conditioning and rehabilitation programs, and familiarity with OSHA recordkeeping requirements, in addition to recognition, evaluation, and treatment. 2. Occupational health care providers (HCPs) can identify high risk departments, production lines, or jobs through the passive and/or active surveillance systems. 3. The HCP should perform a CTD evaluation of employees assigned to jobs with known ergonomic hazards or areas found to have CTD problems by the surveillance system. These evaluations should consist of a medical and occupational history, and a physical examination of the upper extremities. 4. The treatment algorithm emphasizes that a) symptomatic employees need follow up to determine the effectiveness of the prescribed treatments, b) employees with severe symptoms, positive physical findings, or disorders resistant to treatment need to be referred to a physician for further evaluation, and c) conservative therapy deserves an adequate trial before surgical intervention is contemplated.
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Surveillance for cumulative trauma disorders (CTDs) of the hand and wrist was carried out in five US automotive plants from 1985 to 1986, using Occupational Safety and Health Administration (OSHA) Form 200 injury and illness logs and medical insurance claims. Results using both record sources indicated that hand and wrist disorders may be more common in foundries than in other types of automotive plants. Similarly, in assembly plants, employees in certain departments appeared to be at higher risk for CTDs. Although our results are based on small numbers of cases, they suggest plants and departments that might be targeted for more detailed investigation.
The degree of hand preference, ie, the extent to which the use of one upper extremity is obligate, has not been studied previously as a possible risk factor for the development of upper extremity cumulative trauma disorders (UECTDs). This case-control study was designed to test the hypothesis that strong hand preference, whether left or right, would be associated with UECTDs in a working population. Case subjects were drawn from workers who presented to one of two acute care clinics for treatment of work-related cumulative trauma disorders of the upper extremity. Control subjects were drawn from job applicants presenting for preplacement examinations at the same two clinics. The degree of hand preference was determined by the Edinburgh Handedness Inventory of Oldfield. The 48 case subjects evidenced a higher absolute value of the mean handedness score (indicative of a stronger degree of hand preference) than the 134 control subjects (P = .01). As a dichotomized variable, being "strong"-handed versus "weak"-handed was a significant risk factor for UECTD (P = .01, odds ratio = 2.48). Among the 48 case subjects, 83% had a UECTD ipsilateral to the side of hand preference. This study found that workers who develop cumulative trauma disorders of the upper extremity are more likely to exhibit a strong hand preference than a group of applicants entering the work force. These findings suggest that the endogenously determined obligate use of one extremity may be a significant risk factor for the development of upper extremity cumulative trauma disorders.
Symptoms associated with upper extremity cumulative trauma disorders (UECTDs) recently have been reported in professional sign language interpreters. The present investigation is a case control study of potential biomechanical factors that may exacerbate or maintain UECTD-related symptoms in this occupational group. Based on the results of a medical screening, interpreters were classified into two groups: working with pain (n = 16) and working without pain (n = 13). There were no significant differences between the groups on age, gender, years signing, years interpreting, and wrist and forearm endurance and flexibility as measured during an isokinetic strength test of the upper extremities. Subjects were exposed to a standard interpreting task. Groups were compared on measures of repetitiveness of hand/wrist motion, work/rest cycle, postural stress, and smoothness of movement. Heart rate, pain, fatigue, and perceived reduction in extremity flexibility also were measured. The group working with pain demonstrated a distinct pattern of potential biomechanical risk factors previously associated with UECTDs in other occupations. By comparison with the control group, those working with pain exhibited fewer rest breaks, more frequent hand/wrist deviations from neutral, more frequent lateral excursions from an optimal work envelope, and more rapid finger/hand movements while interpreting. Significant group differences on self-report measures of pain, fatigue, and perceived limitation in range of motion also were observed. An analysis of heart-rate response to the interpreting task revealed that both groups demonstrated a modest increase in heart rate to the interpreting task, although interpreters working with pain displayed lower heart rates across all phases of the experimental task.(ABSTRACT TRUNCATED AT 250 WORDS)
This paper discusses the potential roles of work pace and work pressure as risk factors in the development of cumulative trauma disorders. Specifically, electromyographic (EMG) data were collected from the forearm flexor muscles of workers performing a highly repetitive task. This task had previously been identified as one that involved a high incidence of cumulative trauma disorders. Workers were asked to increase and decrease their work pace for short periods of time. The EMG data indicated that faster work paces were accompanied by higher forces. However, it was also noted that unsuccessful attempts to speedup or slowdown produced similar increases and decreases in EMG activity, indicating that speed of movement was not the only factor contributing to the changes in muscular activity. The results are discussed in relation to the stress and tension associated with work pressure caused by machine pacing, production standards, and incentive systems.
Workers' compensation claims in Ohio were evaluated as a source of surveillance data for identifying workplaces at high risk of cumulative trauma disorders (CTDs) and analyzed for their demographic and industrial characteristics. During a 5-year period (1980 to 1984), 6,849 workers' compensation claims met the case criteria for CTDs. Tenosynovitis due to continuous motion was the most frequently reported condition (58%), and the wrist was the body part most frequently affected (48%). The highest case rate was observed for female workers in the 36 to 45 age group. Incidence rates for individual companies were determined and those with the highest rates for CTDs were identified. The employer-specific rates for CTDs based on workers' compensation claims data can be used as an effective surveillance tool in locating high-risk operations where ergonomic interventions can be implemented to reduce CTD hazards.
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Over the past 10 years, Ethicon, Inc., has developed a successful program for the management of cumulative trauma disorders. The program is based on a multidisciplinary approach created through the existence of an ergonomics task force. Various functions of the task force and examples of its operations are described.
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A total of 574 active workers from six different industrial sites were categorised into four force repetitive exposure groups. Workers in low force-low repetitive jobs served as an internal comparison population for the three other groups. Videotapes and surface electromyography were used to estimate hand force and repetitiveness. The presence of cumulative trauma disorders (CTD) was determined by structured interview and standardised non-invasive physical examination. Only workers who had been working on the study jobs for at least one year at the time of evaluation were eligible for selection. Categorisation of jobs and identification of CTDs were carried out independently by investigators who were appropriately blinded to exposure and outcome. The analysis of associations between CTDs and exposure categories were performed using Mantel-Haenszel plant adjusted odds ratios and unconditional multiple logistic regression. Significant positive associations were observed between hand wrist CTDs and high force-high repetitive jobs. These associations were independent of age, sex, years on the specific job, and plant.
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